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76A 642D — CE808 — 9/73 APPLICATION FOR PERMIT
• COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS 5803 N. Agnes Ave.
LOCALITY Temple Cit
NEAREFADDRESS
OR APPLICANT TO FILL IN CROSSSTL,>a
Rosemead Construction
ION LOT NQ,�4p�� OWNER
_ MAIL
TRACT 41 ADDRESS 2 S. Atlantic
NO OF BLDOS 7'
OT NOW ON LOT CITY Monter ark TEL NO95131 10-9513
DISTRICT NO GROUP MAP PRO SSED BY
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�r76 N B dW1n AveO CONNECTION DATr•1 Moante TEL NO443--0070 STATION DEPTH
STATE 231 I'1 LIC C
MANHOLE REFERENCE UPPER
LICENSE NO T OLAS LOWER
36-20
NO I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TOP L
PUBLIC SEWER 0 $7 00
SEPTIC TANK SEEPAGE PITWOR
J C NO
PITS AND/OR DRAINFIELD Q SIO 00 CO IMP NO OB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEMf $300
CONNECT ADDITIONAL.061000MER AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT DRAINFIELD O
EXTN CESSPOOL DRYWELL� $500 V
ALTER REPAIR OR ABANDON HOUSE
HWY ORST WIDENING
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT CD
MANHOLE $700 PERMIT NO C-7)
INDUSTRIAL Lj
a
WASTE APPROVAL
OWNER S PERMIT $ CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER )7 APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
ti
OWNER OR b, NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(8)
AND STATE THAT THE ABOVE4,IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS . > CESSPOOL ❑ DRYWELL _
I HEREBY CERTIFY THAT AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWEROR
CE
LINSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CA�I FCANIA OR T AT M THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE A SCRIBED R ENTIAL PROPERTY
y ABANDON HOUSE SEWER
SIGNATURE
OF PERMI`TTEE S`C BACKFILL SEPTI NKS ❑
�
SEEP PIT(S) C SPOOLS ❑
VALIDATION CK M D CASH
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