HomeMy Public PortalAbout10667 ROSEGLEN ST_Sewer__ D1EPAJCC&U9aqT OF OOUNTY m7COXEM SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COU= OF LOS A-WOM 8
WILLIAM J. FOX. COUNTY KNOINQR BUILDING A
ADDRESS V lb
FOR APPLICANT TO RLL IN LOCALITY
BUILDING
ADDRE'88 10667 ROee Ger St. NEAREST
LOOALITY Tampla qit F DrSTRIDT Y0. SKMAL NO. P[RrfT NO.
CRm ST. El Mmt e A �2
N EIV D BY Naso tar Ima+.atfa� DATE ISSUED
OWNER
/,I-.MAIL I(,
ADDRESS 272 -k San 3a-hr113I Blvd. ua[zoN[ 0 PANCY MAP
BK PG
CITY 6gAn Oeb r l a TEL.NO. AT 94364 - 4 — / _
CONTRACTOR L.D. & M. Om s tr. Co, =-W"O.
ADDRESS 21 W. Wistaria Ave. JOB NO.
CITY Aroodi A TEL.NO. DO 62238 TRUNK PERMIT NO.
ST
REGISTRATION NO. ],],`36�,'� (' COUNTYATE ROAD PERMIT NO.
LEGAL C STAT[ENCROACHMENT
DESCRIPTION LOT N0. Uy PERMIT NO.
BLOCK TRACT 19189 INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT Y0.OF BLDGS.
YOW ON LOT CHARGES
UBE OF
BUILDINGS Hes. & Gexage CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER 00YYEOTINO TO
REIMBURSEMENT FEE
1 PUBLIC SEWER ! / > 5Q BECEIPT Y0. DATE BY
HOUSE sEwElt CONN NG TO
PRIVATE DISPOSAL SYSTEM Im
CONNECTONAL BLDIL Oil EXCEPTION RE EO
WORK TO HOUSE SEWER 1.00
ALTER8k RtPAIRY NO. D E BY
SEWER OR DISPOSAL SYSTEM Im
D184DONNE AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.09 CONNECTION DATA
SEPTIC TAN -a R
PITS AY OR DRAIIIFIELD 2AQ STATION 'i d DEPTH
LL
8PECIAL CONDITIONS ONLY !.M / M NHOLE REFERENCE
S UPPER bGwNR
TYPE OF OONNE IONLENGTH FROM /
OWNERS PERMrr $ I 00 ftekwm P.L. L/ M.L.TO P.L. 3 �
AUTHORIZATION TOTAL.FEE 41 50
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPEOTONYSiIGNATURE DAT[
DWELLING TO THE PUBLIO SEWER
SIGNED THIS DAY OF 19— NEW Hous[SEWER
OWNER OR CONNECT ADDITIONAL
OWY[RS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS AMD ORD NFIELD
1 HERESY AGKNOWLEDG[ THAT I HAVE READ THIS APPLI- DE88POOL E] DRYWELL E]CATION AND STATE THAT THE A130VE IS OORREOT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STAT[ LAWS ALTER NEPAIREWEB OR
REGULATING PLUMBING AND SEWERS EWA
E DISPO L SYSTEM
I HERE13Y CERTIFY THAT IAN PROPERLY REGISTERED ONN
AND/OR LICENSED AS REQUIRED BY LOS AECT PLUG AND
ANGELES COUNTY DISCONNECT
HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RMDENTIAL PNOP[RTY. OACKFILL SEPTIC TA []
SE[P.PITM OESSPOO
On. LS
SIGNATURE L. D. d1 bd. tr,
OF PERMITTEIr
TSAAUD M 7./63 r�- - ✓ ���._'_�'t.27 _ C%
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