HomeMy Public PortalAbout4912 ROSEMEAD BLVD_Sewer__ 76,'64213 APPLICATION :.V A_
;.FOR PERMIT
6 1
11 E•663 12-54
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING ie, /fl
WM.J. FOX, COUNTY ENGINEER ADDRESS d► �r !�
MMMO
CASSATT D. GRIFFIN,SUPT of BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST 1��� 8
CRST.
OSS J �j
LEGAL e'6 j;✓ri.0 C7J E1�ti
DESCRIPTION LOT NO. OWNER
BLOCK TRACT �S 9 G See IT, MAILRESS �,&� e
ADD
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT _ CITY TEL. NO.
USE OF
BUILDINGS P-0;5 e DISTRICT NO. GROUP I( �] MAP
CONTRACTOR /C's /8 S P1L1 c t is SLI AS PG
I - I O0'®K"-' -7.3
ADDRES/sS1 �'-�® a.0 ��,, , ! CONNECTION DATA
CITY TEL. N0. STATION DEPTH
!llllr '1 �� ® _ MANHQI.E REFERENCE
REGISTRATION NO. Q COUNTY LOWER
TYPE OF CONNE P.L' LENGTH FROM
NO. DESCRIPTION OF WORK FEE Y. CURB M.L. TO P.L. '_-
HOUSE SEWER CONNECTING TO
PUBLIC SEWER n $ 3.50 gA 4
HOUSE SEWER CONNECTING TO �.
PRIVATE DISPOSAL SYSTEM 1.00_
CONNECT ADDITIONAL BLDG, OR CO. IMP. NO. - JOB. NO.
WORK TO HOUSE SEWER 1,00 '7
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
_AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE J/1 REIMBURSEMENT FEsiEI HAVET�+.
TRACTORTTOS CONNECT THEDATEA CTED ABOVEWITH DESCR BED EXIISTINGTHE HEREINA DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER,
SIGNED THIS�_DAY OF 1 f--h-19
NEW HOUSE SEWER z — �XQArA
OWNER ORA� CONNECT.ADDITIONAL
OWNERS AGENT �0� BUILDING OR WORK
SEPTIC TANK, SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. - SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER.
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. Jp BACKFILL SEPTIC TANKS❑
t �6 ��J SEEP. PIT(S) ❑ CESSPOOLS
_.
SIGNATURE
OF PERMITTEE
WILLIAM J. FOX,COUNTY ENGINEER VALIDATION
BY BY. —
DEPUTY DEPUTY'
BY BY
� ® DEPUTY DEPUTY