HomeMy Public PortalAbout6127 TEMPLE CITY BLVD_Sewer__ �45A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL' �
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 13 U I L D I N c
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JOHN A. LAMRIE County Engineer
WILLIAM A. JENSEk, Supt of Building
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ADDRESS TION DATA -------
STATION DEPTH
CITY '-IEL, NO.
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MANHOLE RE E:RENCE
REGISTRATION NO. Z�- ❑ COUNTY
NO. DF.SCRIPfION OF WORK FEE TYPE OF CONNECTION LENGTH F0.0m,
HOUSE CURB P.L. TO IA:L.
PUBLIC SEWER
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PITS AND/OH DRAlNFIFLD @ Co._IMF NO.
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USF SEWER TING TO I .
-IVAE O!5FOSAL SYSTEM N cy .
7TRUNK PERMIT NO. ROAD PERMIT
ss 00
-BL.b�, I I AFFIDAVITWAIVER EASCRVAITRE &RD. I si�RNO.
DATE
WORK TO HOUSE SEWER @ $.3,00
PRAINFIELD
EXTN CES 5,POOI,DRYWEL-.MANHOLE@ $5.00
HWY. OR ST.WIDENING
ALTER,REPAIR OR
St-,WER OR DISPOSAL SYSTEM
STATECNCROACHMENT
PERMIT NO.
------ INDUSTRIAL
WASTE APPROVAL
CHARGES
OWN R'SERMIT zi 00
N'
CONNECtIOCHARGE FEE
AUTHORIZATION I TOTAL. FEE --------
I HAVE AT THIS DArL A CONTRACT WITH THE HEREIN XAMED CON REIMBURSEMENT FEE
TRACTOR TO CO"4 NECT THE ABOVE DESCRIBED EXISTING DWELLIU�G
TO THE PU a L IC 5 EWER. APPROVALS i DATE INSPECTORS SIGNATURE:
SIGNED THIS DAY
OWNER OR NEW HOUSE SEWER
OWNERSAGENT 1-0-NNFCTADDITIONAL
ADrRESS-,
SEPTIC TANK.SE P,PIT(S)
I HERESY ACKNOWLEDGE THAT I HAVE: READ THIS APPLICATION AND/OR DRAINFIPLD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY —-------
WITHALL COU N.-10-RD(NANCE5 AND STATE LAWS REGULAT114G
CESSPOOL 0 DRYWELL
PLUMBING AND SEW.IRS,
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
L I CENSE LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL.SYSTEM
0 AS REQUIRED By
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO D,
RE CONNECT PLUG AND
qjDF T-AL ;,,II'RTY-
IN, T�H�GYE r E ABANDON HOUSE SEWER
OF PERMITTE BACKE ILL SEPTIC TANKS 17-
EP,PIT(S) CE.SSPOOLS Q
-921 "VALIDATION ROBERT A. WOOD
SUPERVISING MFCHANICAL ENGINEFR
CK. M.O. CASH
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