HomeMy Public PortalAbout6012 TEMPLE CITY BLVD_Sewer__ 76A642D TEMPLE CITY
ZE8081REV.6/781 APPLICATION FOR PERMIT
P�5
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP BK MAP PG PROCESSED BY
BUILDING
ADDRESS 602.2 N. Temple City Bl.
LOCALITY CONNECTION DATA
NEAREST STATION DEPTH
CROSS ST.
UPPER
1�
'1° MANHOLE REFERENCE LOWER
OWNER Edwards- Yewl in Inv. TYPE OF CONNECTION LENGTH FROM
MAIL1024
C^`, S. 4th Ay. Y, CURB P.L. M.L.70 P.L.
1
ADDRESS �/L�.
P.G.NO.
p
CITY�LrCadic`l TEL.No446-3737
CO.IMP.NO. JOB NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
!.0
DESCRIPTION LOT NO.
61 AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT 65
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY,OR ST.WIDENING
USE OF
BUILDINGSAptSTATE ENCROACHMENT
DeaINDUSTRIALl
NO.
CONTRACTORS ar D a Spew 5ei V C WASTE APPROVAL
ADDRESS '7293 M.axxon 11d. �j�y /y CHARGES
CITY EZ Montt' TEL.NO. "T44-2020 CONNECTION CHARGE FEE
STATE LIC. REIMBURSEMENT FEE
LICENSE NO. Z8870 CLASS C-42
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE (,
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 0
SEPTIC TANK.SEEPAGE PIT OR NEW HOUSE SEWER
ITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM d
CONNECT ADDITIONAL BLDG.OR �� SEPTIC TANK,SEEP.PIT(S) '
WORK TO HOUSE SEWER AND/OR DRAINFIELD _
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL❑
EXTN.,CESSPOOL.DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFI LL SEPTIC TANKS❑
OWNER'S
it
Perm S SEEP,PIT(S)❑ CESSPOOLS
AUTHORIZATION TOTAL FEE c1VALIDATION
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA ED CON-
T RACTOR
ON-TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING \
TO THE PUBLIC SEWER. -
SIGNED THIS DAY OF 19_
OWNER OR
OWNERS AGENT
ADDRESS
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO RE-
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROP RTY.
SIGNATURE ,7 /� ,.j - •
OF PERMITTEE