HomeMy Public PortalAbout6316 TEMPLE CITY BLVD_Sewer__ TeAusD
CESURiGEV e/)RI APPLICATION FOR PERMIT
LDD �
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN oB RIO %o cpROua MAP PDC ED e
euILDING .�J d 8 •`
AJ / T f
ADDweas �� �
LOCALITY G t CONNECTION DAT
NEAREST /�✓ _ / STATION DEPTH
CROSH BT
UPPER
J
MANHOLE REFERENCE ' LOWER
OWNER
�/J / TYPE OF CONNECTION LENGTH FROM
MAIL
r�RA CURB RL METOPE, .
PC NO
CT' ACL/tLf/ TEL NO I �2 a3 MP NO JOB NO
LEGAL KPERMTNO ROADPERMITNO
DESCRIPTION LOTNO
IDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
BLOCK TRACT
NO or"LOGS
Buz OF LOT NOW ON LOT OR ST WIDENING
USE OP
BUILDINGS E ENCROACHMENT
IT NOCONTRACTOR O / � STRIALE APPROVALADDRESS CHARGES
CRYYZL NO ECTION CHARGE PEESTATE LIC BURSSMENTFEELICENSE NO CLASS
NO DESCRIPTION OF WORK PEE APPROVALS DAT[ INSP SIGN TUImHOUSE SEWER CONNECTING �PUBLICSEWCR SAPTICTANK SEEPAGE PITOR ROUSE SEWERPR6AND/ORDRAINf1ELD ECT ADDITIONALHOU9s86WlRCONNECTNGTO DING OR WORKKTANK SEEP PRI31
CONNECT ADDTIONAL"LOG OROR URAINPI[LDWORKTOHOU"ESEWER _OVERFLOW SEEPAGE PIT DRAINFIELD POOL O DRYWELL❑
EITN CEsSPOOL,DRYWELL MANHOLE
ALTAR REPAIR OR ABANDONHOUSE ALTER REPAIR SEWER OR
AM[R OR DISPOSAL SYSTEM gEW AOl DISPOSAL SYSTEM
DISCONNECT PLUG AND '
ABANDONHOGBEBEWER
BACKFILL SEPTIC TANKS o
Permit Al _ BEEF PIT is) CESSPOOLS❑
OWNER'S - VALIDATION
AUTHORIZATION TOTAL FEE ON 0 ; ,- a-7 9 5-
TRACTOR — 7
I HAVE AT THIS DAT[ A CONTRACT ESC IBE HEREIN NAMED CON
OTHffTO CONNECT THE ABOV!DESCRIBED E%ISTINO DWELLING 3 A
TO TM[PU[LK 6[W[R II t
SIGNOOTHIS - PH AYOR 19_ - E • E A 0
OWNER OR
OWNERS AGENT _ 2 E e 1 OO 0 O _
ADDRESS
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION E E o 1 o0 0 0 6
AND STATE THAT THE ABOVE Is CORRECT AND AGREE TO COMPLY
WIHALL Me Hi O As N' ORDINANCES AND STATE LAWS REGULATING RS, .I 1. 14-78
1 HERSEY,CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED EY LOS ANGELES COUNTY ANO STAT[OF
C FORNIAORTHATIAMTHELEOALOWN[ROP ANDINTENDTORE
[IDE IN THE AEOVA DESCRIBED RESIDENTIAL PROPERTY
SIGNATURE
OF PIRMIRE �