HomeMy Public PortalAbout4940 ROSEMEAD BLVD_Sewer__ ]DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
CASSATT D. GRIFFIN, SUPT OF BUILDING ADDRESS rte°' '' +' .
FOR APPLICANT TO FILL IN LOCALITY t f
BUILDING NEAREST
ADDRESS ` CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A �J '''�
CROSS ST. 15
j Rrt�7IVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL
ADDRESS - L �— Y� USE ZONE OCCUPANCY MAP
BK PG
CITY J!7 `� /TEL.NO.
CONTRACTOR ! CHARGES REIMBURSEMENT FEE
ADDRESS REQUIRED
NOT REQUIRED
CITY TEL.NO. JOB.NO. CONNECTION CHARGE FEE
STATE
REGISTRATION NO. COUNTY CO.IMP. NO.
LEGAL RECEIPT NO. I DATE IBY
DESCRIPTION LOT N0.
BLOCK TRACT WAIVER FOR RECORDING
SIZE OF LOT NO.OF BLDGS.
USE OF NOW ON LOT RECEIPT N0. I DATE I BY
BUILDINGS TRUNK PERMIT N0.
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ROAD PERMIT NO.
PU_BLICSEWER Q $ 3.50
HOUSE SEWER CONNECTING TO STATE ENCROACHMENT
PRIVATE DISPOSALSYSTEM 1.00 PERMIT NO.
CONNECT ADDITIONAL BLDG.OR INDUSTRIAL
WORK TO HOUSE SEWER 1.00 WASTE APPROVAL
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 STATION DEPTH
SEPTIC TANK,SEEPAGE PIT OR <'
PITS AND/OR DRAINFIELD 2.00 MANHOLE REFERENCE
CESSPOOL—DRYWELL I I UPPER LOWER
SPECIAL CONDITIONS ONLY 2.00 TYPE OF CONNECTION LENGTH FROM
Y. CURB P.L. M.L.TO P.L.
OWNERS PERMIT $ 1 00
AUTHORIZATION TOTAL FEE > . f
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS I NSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER 1
SIGNED THIS___: -�---_-DAY OF......1,__-��*-_________________ 19.__: NEW HOUSE SEWER
OWNER OR /-.` CONNECT ADDITIONAL
OWNERS AGENT---- ----- f ......... --------- - BUILDING OR WORK
ADDRESS------------- 1 --- ---------------•----------•- AND/OR DRAINFIELD PIT(S)
7SEPTIC
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI• CESSPOOL 0 DRYWELL El
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR SEWER
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS E]
SIGNATURE SEEP.PIT(S)[:] CESSPOOLS
OF PERMITTEE---------
--- - - ..... —" -
,6A64ED 663 12/5•L
APPLICATION FOR P RMIT
SEWER---SEWAGE D POSAL
COUxrr of ups ANa�a
DWAHTMELR OF COUNTY ENCOCEM
BUIIXMG AND SAFETY DAMON BUILDING
ADDRESS
TOEN A. r.QRWF
CASEUrr D. OAF . bvp') of
X EARFST
FOE APPLICANT TO FILL IN CROSS ST. W.
LEGALtv
DXl"IPTION IAT NO. OWNHR
BLOCK TRACT MAIL
ADDRESS
X0.OF SLOGS.
SIZE OF LOT NOW ON LOT CrIT
USE OF.
BUILDINGS DISTRICT NO. GROUP P CE9SED By
_ K
CONTRACTOR V
ADD2E= oN rA
C ' TEL N0. eTATiON 3�. DEPTH
IIANHOLY REF 3LEXCE
REGIsrRAnoN no. �- cou ,
No, uuDaa DESCRIPTION 0 FEE
PUBLFCSEf'ER CONNECTING TO
Efi7ER 3,00 !O TYPE OF CONNECT= LKNGTH FROM
SEPTIC T NK,SEEPAGE PIT OR T. CURB P.L ■.L TO P.L.PITS AN OR DRAINFIELD 9 $1,00
OVERFLOW SEEPAGE PIT,DRAINFIELD
HOUSE ER CONNE;W GTO +� �, P.C.X0. `
p Y 00 CO.1 No. -�---V f l JOB Xo.
'WONRK TO HOUSEIONAL BLDG.OR TRUNK PERMIT X0. ROAD PERMIT NO.
SEER •
fi�lr,R PA OR ABANDON HOUSE BTATEBXCROACHiIENT
SA 1.00 PERMIT N .
INDUSTRIAL
W PROTA
CHARGES
OVPNm's PERMT 2 00 CONNECTION CHARGE FEE
AUMOEPLATION TOTAL FFA REIlBURSEMEXT FEE
I HAVE AT THIS DATE A CONTRACT WIT THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED WSTING DWELAJNG APPROVALS DATE INSPER'/SIGNATURE
TO THE PUBLIC SEWER
SIGNED TEiI sf{ � 9_ NEW HOUSE SEWER !7
OWNER OR CONNECT ADDITIONAL
OWNEYS AG BUILDINWOR WORK �T
A,DDF SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND DTATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLT CEYSPOOL DRTWELL
WITH ALL COUNTT ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER 0E
PLUMBING AND SEWERS. ASTER,RE AIR,S ER OR
L HERKBT CERTIFY THAT I AM PROPERLT RRpISTERED AND/OR DISCONNECT PLUG AND
EM
LICENSED AS REQUIRED By LOS ANGELES COUNTY AND STATIS OF �NDON HOUSE SEWER
AND
CAlJFO IA OR T I AN THE LEGAL, OWNER OF THY YTi
DESCRIB RES1D AL PRO BACKFILLC TANKS L4 01
di0XATURIK SEEP.PITS CESSPQO
OP PERM
mr VALIDA ROBERT A. WOOD
Qi. L 0. 8LVP131VISING hLXCktAtiICAL itiOINETR
Lf t30 2 4 8_3 FED 14 1 DID 6.0 0