HomeMy Public PortalAbout5709-5711 TEMPLE CITY BLVD_Sewer__ I f
CESOSS 62
TBAeASD APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES ,` SEWER-SEWAGE DISPOSA /
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
WMA
LAMBRI CBupty Lp�o{n ADDRESS .�
WII.i.111E6 A IBFBER BBP t Men
n
LOCALITY
NIARCfT
FOR APPLICANT TO FILL IN D"Dea {T
L
DEIRIPIION LOT NO
COWNER
MAIL-
BLOCK TRACT Of AODREaa —7
NO OF pLD06 _
812E OF L.T,60
—BUILDINGS NOW ON LOT CITY TEL NO
UOF DISTRICT NO MAP PROCCS D BY
OK PO �
CONTRACTOR _
ADDRESS CONNECTION DATA
CITY TEL NO STATIONDIPTH
STATE MANHOLE REFERENCE
REGISTRATION NO O COUNTY LOWER
NO DESCRIPTION OF WORW FEE TYPE OF I N LENGTH F
HOUSE SEWER CONNECTING TO Y CURS P L M L TO P L
PUSLICSIWER Q III.GO PC NO
SEPTIC TA SEEPAGE PIT OR CO IMP NO JOB N0
PITS ANO/OR GRAINFIELD ® sic 00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROM PER MIT O
PRIVATE DISPOSAL SYSTEM []OO
CONNECT ADDITION AL BLDG OR AFFIDAVIT {YY[[ a.V[{[IIT RECIND INSTR O DAT
WORK TO HOUSE SEWER O CI OO
OVERFLOW SEEPAGE PIT GRAINFIELD
![TN CE{SPOOL ORYWELL MANHOLE O ES 00
ALTER REPAIR OR ABANDON HOVfE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM B C!00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
O YY NER'SCHARGES
PERMIT f z o0
AUTHORIZATION I TOTAL FEE 1 10100FHE
CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONNT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLINGOVALS
TO THE PUBLIC {EWER A�/p/7�r � T IR[PEROR 881 GNATUR[
SIGNED THIS DAV OF
/ 19_
OWNER OR / WER
OW NCRB AGENT [_/1� ITIONALADDRESS ORK
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BCPTICTANK SEEP PIT(S)
ANDlOR DRAIHFIELD
AND STATE THAT THE ABOVE IE CORRECT ANO LAWS
TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS "EOU LATINO
PLUMBING AND SEWERS CESSPOOL ❑ OflTW[LL ❑
1 H[R[BY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DIBPOBAL•YSTCM
CALIFORNIA OR THAT THC OA OW [R OF AND INTEND TO DISCONNECT PLUG ANO
REBID! IN THE A[O BCRIB R 1 TIAL PROPERTY ABANDON HOU5[•6WER
IF
SIGNATURE
OF P[RMRTIE BAGKPILL SEPTIC TANKS ❑ of
SEEP PIT(q ❑ CCSSPOOIE
OAMATION ROBERT A WOOD
eK M O CASH SUPERVISING MECHANICAL ENGINEER
LAC60 5 6 1G FEB 4 1 0 D 10.00-
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