HomeMy Public PortalAbout4930 ROSEMEAD BLVD_Sewer__ -� 246 NSERTS
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76A642APPLICATION FOR PERMIT
6A842D COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, Couaty Engineer
WILLIAM A. JENSEN, Supt of Building LOCAL
NEAREST
FOR APPLICANT TO FILL IN CROSS Sr
LEGAL O
DESCRIPTION LOT NO.
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF ITA
ISTRICT N0. GR MAP PROCESS Y
BUILDINGS EEEyyy
CONTRACTO ✓/ry I K` G
ADORES J (� CONNECTIO DATA
CIT EL.N0. STATION C ODEPTH MANHOLE REFERENCE O UP RREGISTRATION N0. /NO. DESCRI TION 0 WORK FEE
HOUSE SEWER CONNECTING TOPUBLIC SEWER @ $3.00TYPE OF CONNECTIO LENGTH FROM
SEPTIC PITS AND/OR DRAINFGIE PIT OR @ $3.00Y. CURB P.L. M.L.TOP.L.OVERFLOW SEEPAGE PIT, DRAINFIELDEXTN.. CESSPOOL, DRYWELL@ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00CO. IMP. NO. JOB NO. 0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. U
WORK TO HOUSE SEWER @ $1.00
SEPAIRO R ABANDON
HOUSE STATE ENCROACHMENT
PERMIT N0, p
WER OR
INDUSTRIAL U
WASTE APPROVAL Ww
CHARGES W
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY A NOWLEDGE THAT 1 HAVE RE44 THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEN L PROPS TY. BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS
SIGNATURE ❑
OF PERMITTE
OF VALIDATIO7 ROBERT A. WOOD
Ca, m.o. CASH SUPERVISING MECHANICAL ENGINEER
j0 4 3 5% M19 1 0 D 7.00N 4