HomeMy Public PortalAbout4920 ROSEMEAD BLVD_Sewer__ DEPARTMENT OF COUNTY ENGIN jEd�1 �SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFET PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADD RE S ���
FOR APPLICANT FILL IN LOCALITY
BUILDING NEAREST�-"j"j "�
ADDRESS / CROSS ST. L. -INT-'C_J. F w4
LOCALITY DISTRICT NO. SERIAL NO. t PERMIT NO. C
NEAREST A �O t J
CROSS ST. RECEIVED BY Ready for Inspection DATE ISSUED
OWNER F
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MAIL USE ZONE' OCCUPANCY MAP
ADDRESS , BK PG
CITY TELAO.
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ADDRESS A JOB.N0.
CITY � .NO. TRUNK PERMIT N0.
❑ STATE
.REGISTRATION N0. � ❑'COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDG$. CHARGES
NOW ON LOT
USE
BUILDINGS CONNECTION CHARGE FEE
"
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 3.50 RECEIPT NO. I DATE 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 NO- 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 2.00 100 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS I PERMIT $ I 1 00 Y CURB P.L. M.L.TO P.L.
AUTHORIZATION TOTAL'FEE i �G
CONAED NTRACTOR TO CONNECT THTE ED ABOVE D SCRIBEDWITH THEIEXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS.......-_.........DAY OF.............._._.__...__.1......19_.-. NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT....................................................................... BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS--------------------------......................-......... - - - -.: AND/ORDRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[:] DRYWELL
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 AND
DISCONNECT PLUG
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROP RTY. BACKFILL SEPTIC TANKS
SIGNATURE ¢� SEEP.PIT(S)Ej CESSPOOLS
OF PERMITTEE..... *s - "......... ....
76A642A 03 7/53