HomeMy Public PortalAbout6408 TEMPLE CITY BLVD_Sewer__ `E !BDE "°'
5882APPLICATION FOR PERMIT {�
CEu
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBU Countl LD mnur ADDRESS
C01 LVA% W Jf NAINS Sup t Of HQIId IBg
LOCALITY
REARED]
FOR APPLICANT TO FML IN ROSS ST
DAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT 0
ADDRESS
NO Oi SLOGS
BIZ[ OF LOT Q 140
NOW ON LOT CITY TEL N
US[ OF
BUILFfiC DISTRICT NO GROUP MAP PROCESSED iY
S BK PG
CONTRALTO
ADDRESS CONNECTION DATA
CITY TCL Nozg(tSTATION �tb/L DEPTH If
LIC SE LICENSE UPPER
NO CLA99 C MANHOLE REFERENCE O
NO CESCRI"I N OF WORK FEE TYPE OF CONNECTION LENGTH FROM /
HOUSE SEWER CONNECTING TO O� Y CURB L ML TOPL
PUBLIC BOWER 0 f ! 00
�E ^'� PC NO
PIT! AND/OR DRAINFIELD IT ft0 00 CO IMP NO r / JOB NO
HOUSEO
SEWSP CONNECTING TO PERMIT NO ROAD PERMIT NO
PRIVATE
V
PRVA T! OI9PWIL SYSTEM P f 3 00
CONNECT ADDITIONAL BLDG R AFFIDAVIT R4![l [l[IRIYT RECORD INBTR NO DAT[ O
WORK TO NOUSE SEWER f 3 00
SEWER OR OIl P09AL SYSTEM Q f 300
�FLDW SEEPAGE P11 UNAINFILLE, HWY OR ST WIDENING d
EKTN QlSPOOL MANHOLE O f ! 00 STAT[ENCROACHMENT
PERCOLATION TEST P f ! 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERIS CHARGES
TY 3YLEL J PERMIT s z o0
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
1 HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT IEC
TRACTOR TO CONNECT THE ABOVE DESCRIBED EID[TINO DWELLING
TO THE PUBLIC 8[W! DATE INSPECTOR i SIGNATURE
SIGNED THIS 1 /0 19_
OWNER ON �` NEW HODS[SEWER �y 9
OWNERS
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
HEREBY ACKNOWTHAT 1 HAVE READ THIS APPLICATION
AND {TATE THAT THE
ABO SEPTIC TANK SCEP PITI$I
ABOVE ICORRECT AND AGREE TO COMPLY AMO/OR DRAINFIELD
WITH ALL COUNTY ORD
INANCEE S AND STATE LAWS R[OULATINO
PLUMBING AND SEWERS � CESSPOOL ❑ ORYW6LL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOB ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AMD
RESIDE IN THE ABOVE DES REiI BCD ENTIAL OPEItTY ABANDON HOUSE SCWCR
SIGNATURE
ISACKFILL SEPTIC TANKS ❑ L r..r�7�
BC6P PIT I81 ❑ CESSPOOLS
VAATILID
ON
CR M O CASH
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