HomeMy WebLinkAbout121 OccidentalCity of Burlingame
Public Works Department
Sewer Lateral Test Certificate
Address:
Owner:
Conlroclor Nome:
City Stoff Nome:
Cleonoul [ocollon
M . C--a^,ya.\',
lzl C)cc-n A-.r d*\Iesred Dore: lZ 'la- Z- 3
Building Permil #:W-'oL[u
Encroochmenl Permit #:
E--<
n Rear D Left tr Right
Lolerol Size:
Cleonout:
Commenls ond/ or
Skelch:
!, r*irting tr New tnstallation
Tesl Type:x n AirWoler
Slolus:P Poss tr Foit
Sewer Lateral Condition:
No 10Year tr
Portiol Re Mode 10Year tr
New 25 Year K
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