HomeMy Public PortalAbout6444 TEMPLE CITY BLVD_Sewer__ 9�65C INSFIiS i e y �� y
ueoaa Fo APPLICATION-*k OR PERMIT - , 4, •�•�
Tueeee COs, OP LOS ANGELES SEWER—SEWAGE DISPOSAL 1
DEPAMMENS OF COUNTY ENGV=
BUILDING AND SAFETY DIVISION ,BUILDIN
BUILD 9
OHH A T jR
A ISNmP• =.1—d. _7
-LOCAL
NEAREST
FOR APPLICANT TO FILL IN CROSS BY
LEAL
DESCRIPTION LOT A
O OZ yO �I OWNER
BLOCK TRACT e-� MAIL ^E
L9967 ADDRESS 3
MOOF BLDGS
SIZE OF LOT NOW ON LOT CITY L 7 J
USE OF DISTRICT NO GROUP YAP PB BT
BUILDINGS O
Q 6 ' B PG
CONTRACTOR d �
ADDREss
CONNECTION DATA
CITY TEL 46 81
STATION / S' DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY
No I DESCRIPTION
5EE CR PApTI N F WOR FEE
PUBLICSBEWERCONNECTING TO ASS 00
SEPTIC TANK SEEPAGE PIT OR Y TYPE OF CONNECTION LENGTH FROM
PITS AND OR DRAINFIELD 00 URB P ■LTO P
OVERFLOW SEEPAGE PIT DRAINFIELD
EKT P00 DR Wgo
ROUSE SEWER CONNECTING TO P C NO
RIVAE �IISyP 7S ryry��L M 1 CO ITP RO JOB NO
WORK TO HOUO9EISEW L BLDG OR 0
ER TRUNK PERMIT NO ROAD PERMIT NO
ATER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT 100 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT 5Q 00 CONNECTION CHARGE FEE
ADTHORMATION 1 TOTAL PEE 00 REIMBURSEMENT FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HERINCN-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGAMED PPR
DWELL/NG APPROVALS DATE INSPECTOR SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF H- NEW HOUSE SEWER
OWNER OR N0 CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTICTANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRTWELL
WITH ALL COUNTY ORDINANCE! AND STATE LAWS REGULATING
PLUMBING AND SEWERSALTER REPAIR SEWER OR -
I HEREBY CERTIFY THAT 1 AN PROPERLT REGISTERED AND/OR SEN AGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LE L OtlNER F THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTI L PROPE BACKFILLSC TANK!
SIGNATURE SEEP PITS CESSPOOLS QOF PERMITTE
®I /V.JM1LIDATION OROBERT A WOOD
R &0 CAN BUPRRVIROB MECHANICAL.WOOD
',02089 — = 301 0 0 500 w