HomeMy Public PortalAbout5507 TEMPLE CITY BLVD_Sewer__ 4 D
DA6APPLICATION FOR PERMIT
CERA 1
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION e.ILDIMD !�O'
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LOCALITY
NEAREST
FOA APPLICANT TO FELL IN `RD°' DT _
LEGAL
DESCRIPTION LOT NO OWNER
AIL
BLOCK TRACT .�f�+./ ADORED6 VIIA"
NO OF SLOG[
SIZE OF LOT NOW ON LOT CI TEL NO
USE OF DISTRICT NO GROUP MAP PROC D SY
DUILWNGS
s 0 DK PO
CONTRACTOR L/lI�/♦
ADDRESS G dZ (}¢ 1 CONNECTION DATA
CITY TEL NO �O� Q'V STATION DERT
�( STAT[ UR[
REGISTRATION NO V COUNTY M E R
NO DESCRIPTION OF WORK FC[ TY RC OF CONNECTIONL OT PROM
HOUSE SEWER CONNECTINO TO Y CURD P L L T •L }
PUBLIC SEWER $5m a
SEPTIC TANK SECPAG[FIT OR JO IND O
P ITS AND/OltGRAINFIELD EI000 CO IMP NO JOB O v
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO DE
PRIVATE DISPOSAL SYSTEM d BD OO O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT R.ITO .Y.R[RT RECORD INBTR NO DAT[ W
WORK TO HOUSE SEWER d SD OO
OV[RFL OW SEEPAGE PIT GRAINFIELD
[ETN CESSPOOL DRYWELL MANHOLE O [S OO
A SANDON HOUSE HWY OR ST WIDENING Z
S DIBFOSAL SYSTEM SS DO STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
E�}�p WASTE APPROVAL
O T��Y IYL{1,S z Go CHARGES
P
CONNECTION CHARD[F[[
AUTHORIZATION I TOTAL
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FIJI(
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXIgIl! DWELLING
TO THE PUBLIC APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 1
OWNER ORNEW HOUSE SEWER
OWHG[AOCHT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTICI HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIE TANK 6PIT(D)
AMO STAT[ THAT THE ABOVE IB CORRECT AND AGREE TO COMPLY AHD/OIELD
WIT HALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING
PLU ME No AND SEWS" CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OltALTER REPAIR SEWER OR
LKKNEED AS R[OUIRE0 BY LOS ANGLES C TY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OW OF ANO INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE OLSCRID REBID AL FROCCRTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑ /
OF PERMITTEE 8[EP 'ITIS) ❑ CESSPOOLS (�J�
\/AI,IDA'ITQ] ----- ROBERT A W
CK M D CASH /I SUPERVISING MECHANICAL ENGINEER
Lt,i.oO 7 7 20 UR21 1 0 D 1 0.00~ a