HomeMy Public PortalAbout5524 TEMPLE CITY BLVD_Sewer__ FRoN7(N,�J RES
01008',B. APPLICATION FOR PERMIT
COUNTY Or LOB "C;E ES SEWER-SEWAGE DISPOSAL 1.
DUADnOM OF COUNTY ENGmEES
BUILDING SUMDJNG AND BAPETY DIVISION ADDRESS
JOHN A. IRIMBTR Cam T !gyp
CASSATT D ORWM, Svp,t of SRSdmK LOCALITY ei
NEAREST
FOR APPUCM7 TO FELL CROSS BY
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOTCI N
USE OF ''ww
BUILDINGS W! i DISTRICT N4 GROUP YAP P $ED
CONTRACTOR BE PG�
ADDRESS t '�' CCC��i CONNECTION DATA
CITYJ TEL NO 'o 60 (p O r STATION EPTN
STATE
REGISTRATION NO / C� COUNTY MANHOLE NEVEREx PP
NO I
pDESCRI N F WORK
PUBLIC EWSEWE CONNECTING TO 9 00
EPTIC T�LNK SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
SPITS AND/OR DRAINFIELD S 00 IT CURB P L ■ L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD
EKTN CESSPOOL DRTW�LL MANHOLE $100
HOUSE SEWER CONNECTING TOP C NO
PRIVATE DISPOSAL SYSTEM 100 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEW
�TER pp 1 00
SEWER OR DI�RO$AL SYSTEM HOUSE 1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OVVPIWS I PE MIT 2 00 CONNECTION CHARGE FEE
AUTEOBIZATION I TOTAL PEE Oa REIMBURSEMENT FEE rs
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE - INSPECTOR 9 SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER ,^I
SIGNED THIS ^AY OF Jg_ NEW HOUSE SEWER - f1
OWNER ORCONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADD-w- SEPTIC
DRAINFIELD
I HEREBT ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY CESSPOOL 0 ORTWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECTPLUGAND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AN THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE PROPERTY BACKFILL SE C TANKS❑
SIGNATURE / lEEP PITS CESSPOOLS
OP PERYI
Njr VALIDATlOROBERT A WOOD '
CK ■ o eaea wFsavlelNo AtecHANIcwL eNollaeert
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