HomeMy Public PortalAbout10612 ROSEGLEN ST_Sewer__ DEPA1trM.ENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST
ADDRESS ()AI i jjgQn Glen Wit_ CROSS ST.
LOCALITY 'Temple pity DISTRICT NO. A SERIAL NO. PERMIT NO, c
NEAREST J
CROSS ST. T l iliptiitM Qy � RECEIVED BY Ready for Inspection DATE ISSUED
OWNER P.L. Ma Nutt
MAIL 1 USE ZONE OCCUPANCY MAP
ADDRESS 2791 San Gabriel Blvd. ( BK PG
CITY San Gabribb TEL-NO. AT 94364
CONTRACTOR L-Dy & II CO.EMP.NO.
ADDRESS 21 We Wistaria Ave. JOB NO.
CITY Areadia TELAO. Do* 62238 TRUNK PERMIT NO.
STATE
REGISTRATION NO. 113613 C 42 ❑ COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. 41 STATE ENCROACHMENT
PERMIT N0.
BLOCK TRACT 19189 WASTE APPROVAL
SIZE OF LOT NO.OF BLOGS.
NOW ON LOT Y CHARGES
USE OF
BUILDINGS Rag, & Garagm CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
1 PUBLIC SEWER @ $ 3.50 E.0 RECEIPT NO. GATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING HO• I DATE BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 00 y` Cr►Ia- P.L. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE 4 50
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS....................DAY OF........__.__..._............_....19___.. NEW HOUSE SEWERrRj--
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT........................................................................_...._ BUILDING OR WORK
........._-_-._-..__.-_----_._._... SEPTIC TANK,SEEP.PIT(S)
ADDRESS......
- - - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL El
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE
n SEEP.PIT(S)� CESSPOOLS
OF PERMITTEE---____...._•_....L• D2iC —C®n$ti?�s_.. ...._.__.__.__...
._ .._.
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