HomeMy Public PortalAbout6350 TEMPLE CITY BLVD_Sewer__ 7SAG42 D APPLICATION FOR ERMIT
C 11806
COUNTY OF ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT
COUNTY OF ENGINEER
BUILDING AND SAFETY DIVISION eu1LDINo 3J"o
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LOCALITY
N[AR[aT
LEGAL
FOR APPLICANT TOFU L IIV
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Deacnlmon LOT;;;:f- / owXefl
MAIL
BLOCK TFIA—Af J p ADDRfee
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SIZE OF L JV NOW ON LOT CITY NO
USE 01 DISTRICT NO OROUF MAP PROCESSED BY
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CONTRACTOR ✓✓"
ADDRESSCONNECTION DATA
CITY TEL B 1- -ATION 'DEPTH
.2 STATE MANHOLE nEFERENc6 UPPER
REGISTRATION NO COUNTY
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENaTH•FRO y
HOUSE]EWER CONNECTING TO Y CURB P L N L TO P L
PUBLIC SEWER [S 00 O
SErtIC TANK E[[PAOE PIT 011 FC NO
PEPTIC
ORAINFIELO 0 [1000 CO IMP NO JOE NO BE
MOUSE SEWER CONNECTING TO T11UXK PERMIT NO ROAD PERMR NO
OD
PFIVAT[OISPOSAL SYSTEM ® J]CO 14
CONNECT ADDITIONAL BLDG OR AFFIDAVIT MTO uu[[T RECORD 'MSTR XO DATE
WORK TO HOUSE SEWER 5300
OVERFLOW SEEPAGE PIT GRAINFIELD h
[NTN CESSPOOL DRYWELL MANHOLE Q 5500 Z
ALTER REPAIR OR ABANDON HOU[f HWY ORST WIDENING
SEWER OR DISPOSAL SYST M 53 00 [TATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OMrNMVS PERM f 2 00
CHARGES
AV HORMATION
TOTAL FEE CONNECTION CHARGE FE[
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PU ELIC SEWER A"RmmnOV TU
PATE INSPECTOR 6SION RF
SIGNED THIS A"F
OWMER OR ,/Y/ NEW HOUSE SEWER (QJ
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
6EPTICTANK SEEP PITO)
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUM DING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HERESY CERTIFY THAT 1 AM PROPERLY REGISTER[ ANO/OR ALTER REPAIR S[W[R OR
LICENSED Ae R[GUIR LOS ANGLE COUNTY ANO ATE OF S[WAOE DISPOSALSYSTEM
CALIFORNIA OR THA A THE LEGAL ER OF XD NT[ND TO DISCONNECT PLUG AND
RESIDE IN TH[ VE [SSRI SEO R NTIA RO RTY
ASAND.H HOUSE 6[W ER
SI01 PC MITT / SACKIILL SEPTIC TANKS ❑
SEEP PIT(S) ❑ CESSPOOLS
PAL }{� ROBERT A WOOD
M 0 �
CK M O /cA/ /aH / SUPERVISING MECHANICAL ENGINEER
L,.Lo 8 7 5 5G FEB 19 1 0 D 7.00- a
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