HomeMy Public PortalAbout6341 TEMPLE CITY BLVD_Sewer__ CEBOB 2 iTO PERMIT FOR SEWER
76A 6420 COUNTY OF LOS ANGELES SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING A/ /� _`7j fr �.
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS Y I
COLEMAN W. JENKINS. SUP T OF BUILDING
LOCALITY
FCRNEAREST
R APPLIC NT TO FILL IN CROSS ST.
(PRINT OR TYPE ONLY) _ -
OAL
IPTION LOT NO. OWNER V
TRACT ADDMA gees 1 �.�✓/EIA- 7
F LOT ~ �� NOWOONBLOT` CITY ' T[L,FINGS DISTRICT NO. GROUP CLASS MAP PROCESSED BY
ACTOR i LSS '/ ro>/ � CONNECTION DATA
Q J TCL. NO. r� �V 4` RATION DEPTX
/� LIC / MANXOLEREFERfNCE, J / BBE NO, �� ry GLAB/ -J� 1 ! LOWER
DESCRIPTION OF WORK F![ TYPE OF CONNECTION LENGTH FROM
OUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
U BLIC SEWER O SS.DG P.C.NO.
SEPTIC ANK,SEEPA E PIT OR CO.IMP.NO. Joe NO.
PITS AND/OR GRAINFIELD $IBMOUS[fIWER CONNECTING TOTRUNK PERMIT NO. ROAD PERMIT NO. G-
PRIVATEDISPOSALSYSTEM SawO
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT RMTU uftu.T RECORD.INSTR.NO. DATE WORK TO HOUSE SEWER SsooOVERFLOW SEEPAGE PIT.GRAINFIELD W[TN..CESSPOOL.ORYWELL.MANHOLE O SS.00 J
A .REPAIR OR ABAAIBBMRFBBBE HWY.OR ST.WIDENING U.
SEWER OR Byg6AL SYSTEM Y $S.GO STATE ENCROACHMENT r
PERMIT NO. DE
- - INDUSTRIAL
WASTE APPROVAL CHARGES 2
OWNER'S PEABNI s oo
AUTHORIZATION TOTAL FEF CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DES O EE1 G DWELLING
TO THE PUBLIC READ CONDITIONS BELOW
S[
SIGNED THIS DAY O. t�7 THIS FORM WHEN PROPERLY MACHINE VALI-
OWNER OR
OWNERS AGENT L !.+ DATED BELOW IS A PERMIT TO DO THE WORK
ADDRESS 'Tt fiY .ies•es r /�L DESCRIBED.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION Permittee is hereby authorized to Install the Work
AND STATE THAT THE ABOVE 16 CORRECT AND AGREE TO COMPLY as shown, in accordance with provisions Of Ordin-
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. once No. 2269 and related Ordinances.
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR This permit becomes null and void if work is not coal-
LICENSEO AS REQUIRED BY LOS ANGLE COUNTY AND STATE OF menced within 60 days from date of issuance.
CALIFORNIA OR THAT 1 AM THE LEGAL HER OF, AND INTEND TO OI lI WO[k 18 suspended at any time during ton-
RESIDE IN. THE ABOVE.4ESCR1/ppD RE DE AL P
SIGNATUREr ;]yam '_I j struction for a period of 120 days, or if any work is
OF PERM TTIR[ l GGA �i done on the said building or structure in violation of
the County Ordinances or State laws governing same.
• VALIDATION JACK R. ALLEN
Wo cASH SUPERVISING MECHANICAL ENGINEER
10 SIM
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