HomeMy Public PortalAbout9209 ROSEGLEN ST_Sewer__ APPLICATION FOR PERMIT
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DriBION OF BU MDENG AM SAFETY $EW E EWAG E D I S POSA L
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Of fol UG B
WM.J.FOY, COUNTY r&NaIN ;��j
ADD�8 2 gOSe II Street
CASBATP D. QRI"M,BUr`T OF SUD. LOCALITY T
FOR APPLICANT TO FILL "Y"A 3nc i t a B
LEGAL
DESCRIPTION LOT NO. OWIIE`Ii JA ClIr 'Faber
BLOCK TRACT 24021 w� 272 y4 San Gabriel $ d.
NO. OF BLDGS.
SIZE OF LOT Now ON LOT Cf an a e TEL. NO.
UDE OF Residence
BUILDINGS DIS�CT . oR0[ YAP PQCONTRACTOR L.D.M. 00$$TRVOTION 00 .
ADDRESS P.0i. BO= 208 CONNECTION DATA
CITY n ar . N0. 10 8 3024 STATION �, "� �/ d DEPTHS .
❑ STATE
Y All HO LE REFEREN CS �
REGISTRATION NO. 11361
No. DESCRIPTION OF WORK FEE
•HOUSE SEWER CONNECTIgG TO . TYPE OF CONNE!" LENGTH FROM
T. CURB M.L.TO P J
PUBLIC SEWER 9.50
HOUSE SEWER CONNECTING TO .
PRIVATE DISPOSAL BYSTE■ 1.00
CONNECT ADDITIONAL BLDG. OR S—
WORK TO HOUSE SEWER 1.00 CO IMP XO J
i ALTER OR REPAIR EXULTING
1 SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT X0.
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 STATE HNCROhCHYEIIT
i PERMIT H0.
1 SEPTIC TANK,SEEPAGE PIT OR INDUSTRIAL
PITS AND/OR DRAINFIELD 00
� INDUST APPROVAL
ESSPOOL-DRYWELL
PECIAL CONDITIONS ONLY 2.00 CHARGES
4
0�8 PFT 1 00
CONNECTION CHARGE FEE
S /,
AUTHOREZATION TOTAL FEE 50 REINBURSEMENT FEE
I HAVE DATE COX-
TRACTORTHIS TO CONNECT ITHE ABOVE DESCR BEDRACTED WITH THEHEREIN EXISTINGAMED MEWNG AMOVALS DATE INSP f1QNATUR[
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19— NEW HOUSE SEVER l
01VNER OR CONNECT ADDITIONAL
OWNERS AGENT Now BUILDING OR WORK
SEEP
ADDRESS
#ND CRTNA IELDPIT(1)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CE"PLOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAMS REGULATING ALTER.REPAIR,SEWER OR
PLUYBINB AND SEWERS. 9 W E DISPOSAL SYSTEM
IHEREBT CERTIFY THAT I AY PROPERLT REGISTERED AND/OR
LICENSED AS REQUIRED BY LO
5 ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AY THE LEQAL ER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROP TY. BACKFILL S C TANKS
-4Z4 '/iij�ar 6"' / SSE!'. ITS C ARKS
SIGNATURE
OF PERMITTEd
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2 1 3 009 MM 19 4A 4.50 9�