HomeMy Public PortalAbout6430 TEMPLE CITY BLVD_Sewer__ APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Dep�aenfCounty of County Engineer
of Los Angel" BD
ILDIND
WM J FOX. COUNTY ENGINwA ADDRESS
CAASATT D GRIFFIN,6W T or SYILDINa LOCALITY
FOR APPLICANT TO M IN ctoa�ar
LEGAL
DESCRIPTION LOT No OWNER
BLOC[ TRACT NAIL
ADO ESS
.��.Y no of eLDGa
SIZE OF LOT /�+� NOW ON LOT CITY TEL p0
U!E OF
BUILDINGS DISTRICT NO I GROUP I NAP
CONTRACTOR � �. T/r_ OR PO
ADDRESS SCONNECTION DATA
CITY XO STATI DEPTH
REGISTRATION NO y y 7 6 C yQ COUNTY YA UPPER REFERENCE LOWER
TYPECONNECTION LENGTH FRO
No DESCRIPTION OF WORK FEE T C e p L M L TO p
HOUSE SEWR'PUSL C SEWERCONNECTING TO ® 7 a SO _
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00 __
CONNECT ADDITIONAL BLDG OR r� CO IMF NO NO
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD P IT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
'ND/OR DISPOSAL SYSTEM f 00 PERMIT NO
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR GRAINFIELD Z 00 INDUSTRIAL
CESSPOOL- DRYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY Z 00 CHARGES
CONNECTIO CHARGE FEE (�
Ovfta$w'ws pEpJw S 1 00
1-1
AUTHORtUTION TOTAL. IEE N REIMBURSEMENT FEEI HAVE DATE CO
ON
TRACTORTHIS TO CONNECT THEAABOVE DESCRBEDWITTHEx EREIN EXISTINGA MED DWELLING APPROVALS DATE INSPECTORS SIGMA URE
TO THE PUBLIC�SK ER
SIGNED THISI�DAY O ��- ig-fj-F-6-
NEW rouse SEWER a¢"
OWNER OR CONNECT
D ADDITIONAL
OWNER! AGENT .f.L1�.4�•�1 COWORK
SEPTIC TANK SEEP, PIT($)
ADDRE54 ARD/OR DRAIRFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DAYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAW[ REGULATING ALTER, REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE EPAIR A EWER OR
LICEM1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR SEWAGE EC DISPOSAL
AND
ENSED At REOUIRED BY LOS ANGELES COUNTY AND STATE OF PLUG
CALIFORNIA OR THAT 1 AN T e LEGAL OWNER OF THE ASOVK ABANDON HOUSE SEWER
DESCRIBED RE910fiNT1 Of Y BACKFILL BE C TAN[1❑
SEEP PIT R CE7 LS
SIGNATURE
OF PERMITTEe
WILLIAM J.FOX.COUNTY 01INsim VALIDATION
jr43 17 3S; APR28 4 2.0 0 0
By BY
DEPUTY DEPUTY
BY EY
m DEPUTY 1 _ Jp! DEPUTY