HomeMy Public PortalAbout6335 TEMPLE CITY BLVD_Sewer__ 411MIT APPLICATION FOR
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPAR NEM OF COUNTY ENGINEER
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ADDRESS CONNECTION DATA
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STATE MANHOLE REFERENCE
REGISTRATION NO COUNT WER
No XII 11IDI33ESCggRIPTION OF W RK FEE
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A TYPE
OF ION LENGTH FROM
PITS AND/OR DRAINFIELDT OR Sl 00
T CURB P L ■L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD
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DR 2120
NOOSE EWER CONNECTING TO P C NO
P IY DSI AL YL EM 31 00 CO IMP NO JOB NO p M
WORIKI TO NOOSE(SEWER LDG OR31.00 TRUNK PERMIT NO ROAD PERMIT NO � 8
A T R REPAID OR ABANDON HOUSE 1 GO STATE ENCROACHMENT 0J
OR D ISPERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PEMT 2 00 CONNECTION CHARGE FEE
AUMOFMTION TOTAL FEE 3o 00 REIMBURSEMENT FEE
I HAVE DATE A CONTRACT WITH THE HEREINCN
TRACTORA TO CIONNECT THE ABOVE DESCRIBED EXISTING AMED DWELL/NG APPROVALS DTE INSP'ECT9fi 3SIGNATURE
TO THE PUBLIC !EWER
SIGNED THIS DAY OF 19_ NEW HOUSE S0IIElt OR EWER
OWNERS AGENT CONNECT ADDiTI OVAL a�
BUILDING OR WORK
ADDRESS SEPTIC TANK BEEP PIT(S)
AMD/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY CESSPOOL Q DRTWELL
WITH ALL COUNT ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWER! ALTER REPAIR SEWEROR
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED SEWAGE DISPOSAL SYSTEM
D AND/OR DISCONNECT PLUG AND
LICENSED A9 RE D BL09 ANGELES COUNT AND ND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR TH TH A AY T E G OWNER OF THE ABOVE
DESCRIBED RE91D PR SEEP BACKFPIT S IC CESSPOOUS
TANKS ff
SIGNATURE
OF PERMIT
01 /VALIDATION ROBERT A WOOD
(vQ M 0 CARE SUPERVISING MECHANICAL ENGINEER
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