HomeMy Public PortalAbout6233 1/4-6233 1/2 TEMPLE CITY BLVD_Sewer__ TEMPLE CITY
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GA64 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPAR'[AiEfT7 OF COUNTY ENGINEEE
BUILDING AND SAFETY DMSION BUILDING
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WILLIAM A ]@76@7 Sup i 9s 8mlwae9 Citl
LOCALITYTemple
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PPLICANT TO FILL CROS[ ST
Lon— en
NO At a 01 OWKiRMAIL ADORES[NO OP SLOGS
p� /1N�OW ON LOT CITY TEL NO
OF
ee W Gar. DISTRICT NO GROUP MAP MOClEssw By
CONTRACTOfl #181 �'AWFkr r poC
ADDRESS 2 Maxeon Rd.
� /�� CONNECTION DATA
CITY El TEL NO GI _2020 STATION / / DEPTH
STATE REGISTRATION NO 0 COUNTY MANHOL[R[FERHNCE Y I uR�R
UYC[�r
No DESCRIPTION OF WORK FEE 5 PE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL ML TO P L T
PUBLIC SEWER O [S OO P C NO O
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 0 [1000 CO IMP NOa )7 UOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO BE
PRIVATE DISPOSAL BYST[M O SS 00 1 0
CONNECT ADDITIONAL BLDG OR L AFFIDAVIT RMT[[ [[t[R[MT RECORD INSTR NO DATE W
2 WORK TO HOUSES
OUSE SEWER C S]OG U o0
OVERFLOW SEEPAGE PIT GRAINFIELD a
C[TN CESSPOOL ORYWELL MANHOLE Y 5500 NWY OR ST NOSHING Z
ALTER REPAIR OR ABANDON HOUR[
SEWER OR DISPOSAL SYSTEM S300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARD"
OWNERS PEAM11' f z o0
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FC[
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT F[[
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING wRO`.
TO THE PUBLIC SEWER NYC • DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OW N[RS AO[NT
CONNECT ADDITIONAL // I
ADDRESS BUILDING Ql Q IS
9EPTICTANK SCEP PITISI
1
HEREBY ACK XOW L[OOC THAT I HAVE READ THIS AMLIGTION AND/OR GRAINFIELD
AND
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMFLY
WITH ALL COUNTY 0ROMAN CEO AND STATE LAWS REGULATING
PLUMBING AMD SEWERS CESSPOOL ❑ DRYW[LL ❑
1 HEREBY CERTIFY THAT I AM MOPCRLY REGISTERED AND/OR ALTER REPAIR SEWEROR
LIC
[RS[D AS REOUIR[D BY LOS ANGLES COUN AND STATE OF BEWAOE DISPOSAL SYSTEM
CALIFORNIA OR
THAT I AM HE
LEGAL OWNER AND INT[NO TO D18CONN[CT PLUG AND
RESIDE IN THE ABOVE D[S RISCO REBI..MTl P PERTY ApAryDON HOUSE SEWER
SIGNATURE MCK P ILL SEPTIC TANKS
OF P[RMITT[[ SCEP PITISI ❑ TC a.
VALIDATION ROBERT A WOOD
cK w G CASH SUPERVISING MECHANIGL ENGINEER
LjjLc 6 1 7 00 ecT 5 1 0 0 800- v
1