HomeMy Public PortalAbout6320 TEMPLE CITY BLVD_Sewer__ 7e 42D
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ms APPLICATIONFOR PERMIT
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SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN GISTEICT No DRDIIP
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LOCALITY G CONNECTION DATA
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OWNER
TYPE Of CONNECTION LENGTH FROM
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DESCRfN LOTNO
AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO I DATE
FLOCK TRACT �O Z
NO OF SLOGS
SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
USE OF aUILDINOS AA STATE ENCROACHMENT
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CONTRACTOR (.i
INDUSTRIAL
IAL
A STRPFROVAL
ADDRESS CHARGES
CITY TEL NO CONNECTION CHARGE FEE
STATE LIC / RKDEBURSEMENTFEE
LICENSE NO CUSS
NO DESCRIPTION OF WORK FEE APPROVALS DATE INSP O SIGN TUR
HOUSE SEWER CONNECTING TO _
PUBLIC SEWER NEW HOUSE SEWER
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RPTK:TANK SSEPAGEPITOR
FRS AND/OR DRAIMIELD CONNECT ADDITIONAL.
HOUSE SEWER CONNECTING TO BULD W
IO OR WORK
PRIVATE DISPOSALSYSTEM
CONNECTADDITIONALSLDG OR SEPTIC TANK SEEP PIT1S)
WORK TO HOUSE{EWER AND/OR DRAINFIRLD
OVERFLOW SEEPAGE PR DRAINFIEW CESSPOOL Cl DRYWEI-L❑
E CESSPOOL.DRYWKLL MANHOLK
ALTER REPAIR OR ABANDON HOUSE ALTER REPAIR SEWER OR
6[WER OR D13POSAL BYSTlM SEWAGE DISPOSALSYKTEM
DISCONNECT PLUG AND -
ABANDONHOUaESEWER
EACKFLLL SEPTIC TANKS❑ �
OWNER'S
Permit i SEEP PITISI❑ CESSPOOLS❑I SENSE
AUTHORIZATION I TOTAL FEE /g _ J �� 'VIAL/LIDATION
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREINNAMED CON_ (/(/w�"--�� ^� / • /J — ��
TRACTOR O CONNNERCTTHE AKOVK DESCRIBED EXISTING DWELLING
Ta 1 3 Q 3 R
SIGNED THIS DAY Of 1E_ �/ --
OWNEROR H S E S S 10
OWNERS AGENT
IIDORr�BSS L i e 1 8 Q Q
1HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ll�l
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUM"IRENY,CERTIFY THAT I AM PROPERLY RKGLSTIRED AND/OR 1. 1 4 -78
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO RE
awe IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY
SIGNATURE -
or nRMTTTE