HomeMy Public PortalAbout6330 TEMPLE CITY BLVD_Sewer__ TEMPLE CITY
faaEaEe APPLICATION FOR PERMIT
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COUNTY OF LOS ANGEL" SEWER--SEWAGE DISPOSAL i
DVAIIIH t OF COUNTY ENGDMM
BUILDING AND SAFEST DIVISION ADDRESS
CJWrr'D• =1 AftG LOCALITY
NEAREST
H APPLICANT TO FILL IN CROSS n
LEGAL
DESCRIPTION LOT NO S / F OWNER .O ILL
BLOCK TRACT �IAWP�In MAIL
ADDRESS,4 33o TEM PL-F C/TY D
NO OF BLDGS
SIZE OF LST NOW ON LOT CITY TEL NO
E OF
BUILDINGS DISTRICT NO GROUPYAP PROC BT
PG
CON 0 �1
AOD Q CONNEC110N DATA
CIT1 nAnoNDEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO COUNTY xft / LOWER
No I
I Px DESCRIPTION OF R FEE UBLICSERWER CONNECTING TO
0 Si DO TYPE OF ION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OH T CUR P L ■L TO P L
PITS AND OR DRAINFIELD 00
OVERFLOW SEEPAGE PITS RLAINFIELD
4p 00
HOUSE S p ER CANNA INC TO Do
CO ITP No JOB NO
CONNECT ADDITIONALBLDG OR TRUNK PERMIT NO ROAD NO
PERMIT NO
WORK TO HOUSES 3SEE11YYEE 111 00
ALTER IR OR ABANDON HOUSE STATE ENCROACHMENT
SEWEJ 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL,
CHARGES
OWNER'S PERM 2 00 CONNECTION CHARGE FEE
AUMOBMATION I TOTAL FEE REIMBURSEMENT FEE
I HER
HAVE AT THIS DATE A CONTRACT WITH TXE EIN MED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS I JDA* INSPECTgRj>t,SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER a by
OWNER OR CORRECT ADDITIONAL
OWNERSAGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT($)
AND/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 1$ CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS ALTERS REPAIR
DISPOSAL OR
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR SEWADISCONNECT PLUG AND
EM
LICENSED AS REQUIRED ST LOS ANGELES COUNTY AND STATE OF ABANDON CT PLUGSE AND IlA
CALIFGRNIA OR THAT Y T E LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT P t BACKFILL 68 CTANK9 Ll
SIGNATURE SEEP PIT B CESSPOOL!
OF PERM]'
�T VAMATIO*- -) ROBERT A WOOD
CIt 0. (7) GUPHRV111NG BIECHANIGL KN61N6BE
1ACo 116 0 QI JUL 5 1 O o 7.00- 9
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