HomeMy Public PortalAbout5702 TEMPLE CITY BLVD_Sewer__ °'
76AS.lD APPLICATION FOR PERMIT
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COUNTY of Os ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENTTMENT C
OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
IDRN Am DOY ED {� ADDflESB�
WILLIAM A. TENSER BpD i d C my
LOCALITY
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CROSS RT
F.I.K
N LOT N OWMER
NAIL
TRACT ADOwNO OF SLOGS
T NOW ON LOT CITY TEL NO
'ID° MAP PROCESSED YY
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ADDRESS, p CO CTION DATA
CITY IC B TEL NO ^y� RATION DEPTH
�} STAT[ MANHOLE REFERENCE
REGISTRATION NO /� [/G COUNTY ez s LOWR
NO DESCRIPTION OF WORK FEE 'ry pE OFC ON
LENGTH FROM
/ HOUSE SEWER CONNECTING TO Y URO P L ML TOP L
PUBLIC SEWER C SSW QG PC NO
SEPTIC TANK SEEPAGE PIT CR CO IMP NO !OS NO
PITS AXD/OR DRAINFI[LD 0 SIO OO /J(J
HOU°E SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NOY
PflIVAT.DISPOSAL SYSTEM ® fiM (lYO
CONNECT ADDITIONAL SLUG OR AFFIDAVIT RMT[• [1![Y[YT RECORD INSTR NO DATE
WORK TO HOUSE SEWER 0 SS OO pp '
OVERFLOW SEEPAGE PIT DRAINFIELD
EAlN CESSPOOL URYWELL MANHOLE Y 56 OD
ALTER REPAIR OR ABANDON HOUSE HWY OR BT WIDENING
SEWER OR DISPOSAL SYSTEM C SJ 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER'S CXAflGIB
OWNER'S PEBADT f 2 00
AUTHORIZATION TOTAL FEF Q OO CONNECTION CHARD[FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DISCR B[D M LING
TO THE PUBLIC SEW[ A"ROVAIS DAdE INSPECTOR SBI ONATII
SIGNED THIS DAY OF 19_
OWNER OR XEW XOUS[SEWER
OWNERS A6EMT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SIPTICTANK BEEP PIT($)
I HEREBY A KNO L[00! T wT I HAVL RG THIS APPLICATION AND/OR DRAIMFIELD
AND STATE TN HE ABOVE 16 CORRECT ANp AOREC TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ElDRYWCLL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF AND INT[NO TO DISCONNECT PLUG AND
RESIDE IN THE ABO ERLRIS IAL PROP[11TY ABANDON HOUSE UBEG AND
SIWER
GNATURE
P[RMITTEE BACKFILL SEPTIC TANKS ❑
SCEP PIT(S) ❑ CESSPOOLS
^VALIDATION ROBERT A WOOD
/`ccK / M O CASH SUPERVISING MECHANICAL ENGINEER
(A'O 4 0 1 2 SEP 6 1 0 D 1 0.0 0- Z
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