HomeMy Public PortalAbout9755 VAL ST_Sewer__ TEMPLE CITY
C`A
T.:RAxD 2D ' APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BuILDIMG 9755E Val St
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
COLEMAN W JENKINS SUPT OF BUILDING Temple Cit
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `R°E` `T
rpitian West
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ON LOT NO OWNER e
"AI` 20 Birchcroft
BLOCK TRACT MAIL s
NO OF SLOGS
OT NOW ON LOT CITY TV L NO
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pe8• °IBTRICT NO OflOUP NAP RROC[84[D OYeKCONTRAOR Sewer e i e
ADDR[59 2933 Maxson Rd�.�f��� CONNECTION DATA
CITY E1 Monte TEL NO 444-20210. IOM D
LTATE
IC[MpE NO 1 ff. C-42 MANHOLE REFERINC[ O �T ` LOWER
No DESCRIPTION OF WORK FEE
TY
o ION 'CJ Le"aTMPROM
HOUSE SEWER CONNECTING TO oo Y P L M L TO P L a
1 PUBLIC SEWER 0 L!0° 5 PC NO
SEPTIC TANK SEAPAGL PIT OR CO IMP NO JOB NO O
PITS AND/OR DRAINFIELD C 010 OO 0
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO IS:
PRIVATE DISPOSAL SYSTEM 4 S300 O
CONNECTADO ITIOMAL SLOG OR AFFIDAVIT RMYKO [1[[P[rt RECORD INS" NO DATE
WORKTO HOUSESEWER 0 5300
OVERFLOW SEEPAGE PIT GRAINFIELD
E%TN CESSPOOL DRYWELL MANHOLE 0 [S°° a
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING H
SEWER OR DISPOSAL SYSTEM 0 $3 GO STAT.ENCROACHMENT
PERMIT NO O
INDUSTRIAL
WASTE APPROVAL
OWNERS PE[iN1T f 200 CHARGES
ADTHORMTION TOTAL FEE oo CONNECTION CHARGE F[8
I HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I�}�}�p
TO THE PUBLIC SEWER MOVAM DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
BE"CTANK BEPIT(S)S)I HERESY ACKNOWL[D°E THAT 1 HAVE RSA° TH1E APPLICATION ANO/OR WAINAND STATE THAT TX[ ASOVC Ip COgw[CT AXD A°RE! TO COMPLY
WITH ALL OOU MTY OROINANC[S ANO STAT[ LAWS flEOULATINO ❑PLUMBING AND SEWERS CESSPOOL ❑ L1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIRRLICENSED AS REQUIRED BY LOS ANGLES COON AX0 STATE OF SEWAGE DISPOEMCALIFORNIA OR THAT I AM THE LEGAL OW NIR AND INTENS TO DISCO MNECT PRt51DR IN TH[ ASOV[ DESCRIBED R[SIDEXTIA PRO ERTY AMNOOM HOUSIGNATURE ❑OF PERMTf[C BACKFILL p6 PTSEEP PIT(Sl POOLS
VAATION JACK R ALLEN
cK LIDM O CASH SUPERVISING MECHANICAL ENGINEER
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