HomeMy Public PortalAbout6339 TEMPLE CITY BLVD_Sewer__ X339
CEpOL APPLICATION FOR PERMIT
']a A642A2L COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ,Vh
ADDRESS VV
LOCALITY I C..,
FOR APPLICANT TO FILL IN NEAROSS tTREST PAL 9J,
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DESCRIPTION LOT No OWNER
LEGAL
oRzl
MAIL
BLOCK TRACT K AODRCRt ►yL`
NO OF [LDOY
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF 01lTRICT NO GROUP MAR ROC ED BY
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CONTRACTOR O NN .4S us4f3i btG J /
AODRWGS n&--Q / 1 CONNECTION DATA
CITY G TEL No () d STATION/-7 _ ,37-
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aTAT[ G L LIC C MANHOLE REFERCNCC/ 'l UFP`rtR
LICENSE NO i
No DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB_ PL M L TO P L
PUBLIC SEWER 0 PC NO }
SEPTIC ! NK SEEPAGE PIT OR CO IMP NO JOB NO C.
PITC ANO/OR GRAINFIELD 0 Q
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM 0 K
CONNECT A DDITIONAL SLOG OR AFFIDAVIT RECORD INS" NO DAT[ O
WORK TO HOUSE SEWER 0
OVERFLOW SEEPAGE PIT DRAINFIIILD (J
[FTM C[SSPOOLDRYW[LL MANHOLTO ITE
ALTER REPAIR OR ASANDO O HINT OR ST WIDENING d
BEWER OR DISPOSAL SYSTEM O STAT[ENCROACHMENT N
Z
PERMIT NO
INDUSTRIAL
WAST[APPROVAL
CHARGES
ORS$ PEAM]T f5-0
AOTHOH=TI0N TOTAL FEE CONNECTION CHARD[F[[/�
I HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON R[IMSURS[MEN l/y,
TRACTOR TO CONNECT THE ABOVE DESCRIBED E%16T20 DW[LLINO Al C80VAL3
TO THE PUBLIC 6CW DAT[ INSPECTOR 6 SIGNATURE
SIGNED THIS DAY OF 1977
OWNER OR NEW HOUSE SEWER
OW AERS AGENT
CONNECT ADDITIONAL ,
ADOR906 BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I
HAVE READ TXIt APPLICATION AND/OR
SEEP PITIt)
AND STATE THAT THE ABOVE It CORRECT AND AOR:[ TO COMPLY 'YND/OR DRAINFICLD
WIT" ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 H[R[SY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LL ICENS(D At R(O R:D BY LOS ANGLES COUNT ANDSTAT[ OF SEWAGE DISPOSAL SYSTEM
ALIFORNIA OR 1 AM [ AND INTEND TO DISCONNECT PLUG AND
ESIDE IN T E D RISCO TI ROPCRTYASAXOON NOUS[SEWER
IGNATURE ❑
OF PERM E[ BACKFILL SEPTIC TANKS
BEEP PITIQ ❑ CESSPOOLS
ATTON
K G EAaN
1 7 61=JAN 1LJ 1 v U 9.0 0 AES