HomeMy Public PortalAbout9218 ROSEGLEN ST_Sewer__ '•""'° APPLICATION FOR PERMIT
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DIVMON OF BUIMING AND SAFETY SEWER—SEWAGE D 1 SPOSAL '
Dop=tm*W of Cour Enatmew
County of Los Angel" "ILDING
WM.J. FOX, COUNTY ENGINWM ADDRESf 9218 Romegl Pin S•
rA
C JftATT D. G UMN, Gur+r or Wun-Dme LOCALITY Temple CbLty
FOR APPLICANT TO FILL IN NEAREST
LEGAL 11JackWeber
DESCRIPTION •LOT NO. OVM&R
BLOCK TRACT 24021 MAL -272 )1 Sb.San Gabriel B1
N0. OF BLDG/.
SIZE OF LOT NOW ON LOT CITYs G TEL.
110.
USE OF
DI Residence DISTRICT RO. GROUP YAP
BUILD PG
COWMCTORL. 17. & M. CONSTRUOTION ,.3 � -z- I /s )Z -
ADDRESS P•0• o= 200 /�y�j COMU=ON DATA
cimbal dl in Pk TEL. N0. 108 024 STATI0 '�Z 2 DEPTH
c Tg ■ANHOLE REFERENCE
REGISTRATION NO. 11361'3 Y
no. DESCRIPTION OF WORK FEE
HOUSE(EWER CONNECTING TO 3 O Y TYPE OF. CURBNNECT P L YL EN GrO r L�y
PUBLIC SEWER 3.60
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER 1.00 CO. IEP NO. - ^
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCNNECT AND ABANDON SEWER STATE ENCROACHMENT
ANDPOR DISPOSAL SYSTEM 1.00 PERMIT NO. '
i SEPTIC TANK,SEEPAGE PIT OR INDUSTRIAL
PITS AND/OR DRAINFIELD .00 INDUSWAVE RIAL
CPSBPOOL-DRYWELL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
.OVPNEWS PEWMIT s 1 00
AUTSOBTI.ATION TOTALTM REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED COX- �*n
TRACTOR TO CONNECT THE ABOVE DESCRIBED E;ISTIAG DIVE,I,LING AMOYAIS DATE IKSP GNATURh
TO THE PUBLIC SEW�R
Nn HOUSE!EWER
SIGNED THIS SAY OF 19�
OWNER OR CONNECT ADDITIONAL
OW NERS AGENT �BT SUILDIXG OR WORK
SEPTIC TANK,SEEP, FIT(S)
ADDRESS- DOR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION GffiSPOOL❑ DRYWE-LL❑
AND STATE THAT THE ABOVE 13 COR-REICT AND AGREE TO COMPLY
WITH ALL COUNTY ORDIIIANM AND STATE LAWS REGULATING ALTT1 REPAIR,SEWER OR
PLUMBING AND SEWERS. BKWAGR DISPOSAL SYSTEM
I HERESY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOIN MGELE9 CO AND STATE OF DISCONNECT PLB AND
CALIFORNIA OR THAT 1 AY THE LEGAL THE ABOV[ ARANDOM HOUSESEWER
DESCRIBED RESIDEXTIAL PROPERTY. n BAL1 CCSKS
SCPITS PO
o
SIGNATURE
OF PERM
W)lLL1AM J.FOX,Coupm 6maim 1m VAlaA=N R.A.WOOD,Cmmw Pum. tm"maToA
LG.2 1 3 8 fR WE 19 4 A 4-50 1%
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