HomeMy Public PortalAbout5526 TEMPLE CITY BLVD_Sewer__ CESOS D tG--3
6Aa4 . APPLICATION FOR PERMIT
COUNTY OF LOS/ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF CgUNTY ENGINEER
BUILDING AND SAFETY DIVISION ou1LDINa ..g Q
1 IOHF A LAMLE County EDp� . ADDR[De
WMA I 'Sup t of B°uiktma
LOCALITY
NEAREST
PD..RON
OR APPLI CROSS DT
LEGAL
PTION LOT NO / OWNER
J MAIL
TRACT ADDRESS
NO OF BLDOD
OF LOT NOW ON LOT CITY TEL NO
BUILDINGS
DIDT111CT NO aROUR MAR PRROCESSED Br
GSBK PaCTOR pCOKA 3 / STATION DSPTH
TEL NOSTATI MANHOLE REFERENCEL7'IY�ATION NO COUNTY Op'i LOWER
OESCRI ON OF WORK FEC TYPE OR CONNECTIONLCNGTX FROM
OUSE QEWCR CONNECTING TO Y CURB P L M L TO PL[LIC{EWER Q EBOD aPTIC TANK {[ PA°[PIT OR P C NO O
PITSAMO/°R GRAINFIELD 0 EI000 CO IMP NO JOS NO V
HOU{[{EWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO pE
PRIVATE DI{POtAL{YRIM E3°O O
CONNECT A°DITTOEW RLS° OR AFFIDAVIT xL11EE E�EERDIT RECORD IX{TR NO OAT[
WORKCT AD I IiEW[R 0 53W l0
OVERFLOW SEEPAGE PIT DRAINFI[LD
S%TN CESSPOOL DRYWCLL MANHOLE O SD°O d
ALTER REPAIR OR ABANDON OU H OR D 1 H
{EWER OR DISPOSAL SYSTEM C $3 OO {TAT[ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s z 00 CHARGES
ADTHORIZATION TOTAL FEE `°"N[=*I°"CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FES
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING � O�R*Q
TO THE PUBLIC {EWER fW7 DATE INSPECTOR 5SI6NATUR[
SIGNED THIS DAY OF IO_
OWNER OR NQW'NOu[E-EWER
OW MCPS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK G,
SLPTIC TANK S[CP PIT(S)
1 HEREDY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GEPTICAND/OGRAINFIELD
A. STATE THAT THE ABOVE 1{ CoRR[CT AND AGREE TO COMPLY
W ITN ALL COUNTY ORDINANCES AND STAT[ LAW{ REGULATING
PLU MDING AND SEWERS CESSPOOL ❑ ORYW[LL ❑
I HERESY C[RTIry TH I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWEROR
LICENSED AS REQUIRE O{ ANGLES COUNTY AND STAT! OF $MADE DISPOSAL SYSTEM
CALIFORNIA OR THAT L[°AL OWNER OF wND INTEND TO
RKOID[ 11 TX[ A ISI. RESIDENTIAL PROPERTY ABANDON
H PLUS AND
ABANDON HOU-L SEWER
SIGNATURE BACKFILL B[PTIC TANKS
OF PEflM1TT[E BEEP FIT
❑ CESSPO❑OLS
ALROBERT A WOOD
M 0 C
(`cK✓N l M o wDX SUPERVISING MECHANICAL ENGINEER
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