HomeMy Public PortalAbout6108 LOMA AVE_Sewer__ C✓a a/�-`� - ...
7 6 A 9421Z---(JE•808 - 'J/7`3 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
DDRESS 10$ N. ILomaAt�1 City LOCALITY Temple Cit
NEAREST
FOR APPLICANT TO FILL IN jJ
CROSS 5T. ./LJ_CC'�'.1.-•L'(i(""C'1+'�.y-,rucyB`�
ion
LEGAL Rosemead Cons .
DESCRIPTION LOT,NO. +� J L-J OWNER
MAIL - 1816 San Gabriel Blvd,
BLOCKTRACT ,��9 0 ADDRESSNO. BLDG
SIZE OF LOT' NOWOON LOTS CITY San-Gabriel MTEL. NO 10.
USE OF - DISTRICTNO. GROUP I MAP PROC SED BY
BUILDINGS -BK' PS
CONTRACTOR jqen
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ADDRESS 4265 N. Baldwin Ave. -CONNECTION.DAT
CITY El Monte TEL. NO. "3"/�/��(O STATION DEPTH
STATE MANHOLE REFERENCE UPPER
LICENSE NO;��� � � C —nO GLASS � LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $7.00
P.G.NO.
SEPTIC TANK,SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 CO..IMP. NO.
HOUSE SEWER CONNECTING TO 'TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIV[[I EAS[Y[MT RECORD.INSTR.•NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD U
,
EXTN..0 .ORYWELL. @ $5.00
H WY.OR ST.WIDENING
ALTEREPAIR R ABANDON HOUSE �
SEWER OR SPOSAL SYSTEM .00 STATE ENCROACHMENT
MANHOLE $7.00 PERMIT NO. LLJ
INDUSTRIAL
WASTE APPROVAL N
.[OL
YY1\T.�R,S *� PERMIT $ 0.0 CHARGES
ATTV HOR14ATION TOTAL FEE -CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR To
CONNECT•THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL '
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
IH
ACKNOWLEDGE THAT I 'HAVE=READ THIS APPLICATION .AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE.TO COMPLY
WITH ALL COUNTY ORDINANCES AND 'STATE LAWS REGULATING -
PLUMBING AND SEWERS. -- CESSPOOL ElDRYW ELL ❑
I HEREBY CERTIFY THAT 1 AM-PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND.STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCdtN1A OR T I THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND v
RESIDE IN, THE 0 E DES RIBED RESID L PROPERTY. - ABANDON HOUSE SEWER
SIGNATURE .,O_ BACKFILL SEPTIC TANKS ❑
OF PE4 MiTTEE �"�Y'� SEEP.PIT( ❑ CESSPOOLS ❑
VALIDATION �� tK. M.O. CASH
o
8 7 rJUN 22 1 0 U. 1 4.0 nti .