HomeMy Public PortalAbout6252 TEMPLE CITY BLVD_Sewer__ J 2-70244650 oNMrsC
CAADee Bo APPLICATION FOR PERMI
"""`° COUN" OF LOS ANGELES SEWER-3 AGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER emLDixG
BUILDING AND SACFe,ET mI'�.BDrVISSION ADD ReeS
WIId.uIeAA R. TEMB�av Bav'f a Dm)dmv Louun
NEAREST �
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FOR APPLICANT T °q0� ST
LEGAL ` OWNER
DESCRIPTION
BLOCK TRACT MAIL L
ADDRESS
SIZE OF LOT .lDXINOW ON LOTS
40 Cin 0
USE OF
BUI DING DIIITRIC7 NO GROUP PO YAP BY
[
CONTRACTOR w � A ��s
ADDRESS Q Y CONNECTION DATA
CITTT /TEL NO STATION G, pEPTX
REGI STRATTON NO / COUNTYATE HOLE REFERENCE PPER
No DESCRIPT ON OF WORK FEE
HOUgE SEWER CONNECTING TO
PUBLIC SEWER SS 00 TYPE OF TION LENGTH FROM
SEPTIC TA XK SEEPAGE PIT OR Y UR P L Y L TO P L
PITS ANO/OR DRAINFIELDCy
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN POOL DRYWELLop St 00
HOUSE SEWER CONNECTI GTO P C NO
PRIVATEDISPOSAL CO IMP NO JOB NO
CONNECT ADDI7IO�X/J 1,BLDG OR TRUNK PERMIT XO ROAD PERMIT RO
WORK TO HOUSES ER
ALT R REPAI OR ABANDON HOUSESTATE ENCROACHMENT
1 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION FTOTAL FEE I REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROYAIS DAT INSPECTOR 9 SIGNATURE
TO THE PUBLIC SEWE
SIGNED THI DAY OF NEW xouae SEWER
OWNEROR 7 S AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PR(S)
AND/OR DRAINFIELD
IHFRWf ACKNOWjkDGE THAT I HAVE READ TH13 APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRTWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEMENS 5EWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THA AM THE LE OF THE ABOVE
DESCRIBED REBID AL PROPER BACKFILLSEPUICTANKS El
SIGNATURE SEEP PIT(S) CESSPOOLD
OF PERMITTE
m' /1TALIDATION Ro T wooD
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