HomeMy Public PortalAbout5000 ROSEMEAD BLVD_Sewer__ ceneazn t�iJ`"PLICATION. FOR, PERMIT-'
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COUNTY OF LOS ANGELES• SEWER-StWAGE :DISPOSAL ,
DEPARTMENT OF COUNTY ENGINEER
BUII.DING AND SAFETY DIVISION -• DDRE 11
• n . � 'AADDRES
SS
IN
JOHN A. LAMBIE, County Faigfrieer
CASSATT D. GRIFFIN, Sup't.of'BuUdiag LOCALITY
NEAREST-
FOR APPLICANT TO FILL 'IN CROSS ST..
LEGAL:. O. s ® /T OWNER"
DESCRIPTION 'LOT N0. `
BLOCK ': TRACT �'jS S�' "' Io2 -I J MAIL
ADDR
NO.OF BLDGS."
SIZE OF LOT O 0 X B NOW ON LOT. EL.N0.
USE OF
BUILDINGS DISTRICT"NO GROUP MAP. PROCESSED BY-
BK PG
CONTRACTOR .
ADDRESS CONNECTION DATA
CITY TEL.NO. STATION'-AI+Y 7, O DEPTH
STATE MANHOLE REFERENCE. U"
REGISTRATION NO. 8 COUNTY LOWER
No. DESCRIPTION.OF WORK - FEE
HOUSE SEWER CONNECTING TO
PUBLIC'SEWER @'$3.00 CT�
SEPTIC TANK,SEEPAGE PIT OR •TYPE'OF CONNECTION LENGTH FROM /•
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $2.00
HOUSE SEWER CONNECTING TOP.C:'NO.
PRIVATE DISPOSAL SYSTEM @ $.1.00 CO.IMP.N0,atO Q JOB NO.
1" CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO... ROAD PERMIT N0.
ff WORK TO HOUSE SEWER @ $1.00 O
ALTER, REPAIR OR ABANDON.HOUSE STATE ENCROACHMENT,
SEWER OR DISPOSAL SYSTEM $t.00' PERMIT NO.. "
INDUSTRIAL
WASTE.APPROVAL -
CHARGES
OWNERS: PERNIIT $ Z' ;.00 CONNECTION,CHARGE FEE
AUTHORIZATION TOTAL FEE 1.66- REIMBURSEMENT FEE:
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. I 7
SIGNED"THIS ` AY OF 190 NEW HOUSE SEWER'r °
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK '
YADORES S�Q"1 'SEPTIC TANK,SEEP;.PIT(S).
AND/OR DRAINFIELD'
'I HEREBY'ACKNOWLEDGE.THAT I HAVE READ 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
-
I .HEREBY 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 RESIDE TI• L PROPERTY. BACKFILL SEPTIC TANKS❑ -
SEEP.PITS) ❑ CESSPOOLS' \. �' '
SIGNATURE
.OF PERMITTE - -
®e VALIDATIO '�ROBERTA.WOOD
OK.. M.p, CASg SUPERVISING MECHANICAL ENGINEER
APPLI'CATIOU FOR PERMIT
canoe a-sa COUNTY OF LOS ANGELES
SEWER-SEWAGE DIS SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Bun
ADDRRESSESS
v Q
IOHN A. LAMBIE, County Engineer ,
CASSATT D. GRIFFIN, Supt of Building LOCALITY
.119091 . - 1
10 i FOR APPLICANT TO FILL TN. NEAREST
T !/C
LEGAL.
� OWNER
DESCRIPTION � LOT NQ,
BLOCK TRACT r MAIL
�l o ADD RE (TV�►!' / '/
/� NO.OF BLDGS. o 'a
,1 f
SIZE OF-LOT ,� 76 NOW ON LOT - t�C.i- - CIT EL.-NO. �C.-A- co
USE OF b DISTRICT N0. GROUP. MAP ED BY -
BUILDINGS
I BK PG I
CONTRACTOR
ADDRESS - CO 'C ON ATA. -
CITY EL.NO. STATION DEPTH
❑ STATE MANHOLE REFER CE UPPER
REGISTRATION ❑ COUNTY LOWER
NO. DE52KIRTION OF WORK %FEE
HOUSE SEWER CONNECTING TO '
PUBLIC SEWER @ $3.00 TYPE OF CONNECTIO GTH FROM _
SEPTIC TANK,SEEPAGE PIT OR Y. CURB L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD - - -
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO - P.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB
CONNECT ADDITIONAL BLDG.OR - TRUNK PERMIT NO. ROAD PE IT NO. - -
WORK TO HOUSE SEWER @ $1.00
ABANDON-HOUSE STATE ENCROACH NT
SEWEQ- R DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
_ WASTE APP AL
CHARGES
OWNERS PERMIT S 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
OWNER OR CONNECT ADDITIONAL -
OWNERS:AGENT BUILDING OR WORK -
ADDRESS SEPTIC TANK,SEEP.PIT(S) _
AND/OR DRAINFIELD
.'I HEREBY'ACKNOWLEDGE THAT 1HAVE READ 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
I 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 OWNE OF THE ABOVE -
DESCRIBED RE DENTI PROPERTY BACKFILL SEPTIC TANKS ❑ "'--
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS_ ❑ O`Y,V`iR.
OF PERMITT
®P VALIDATIO - ROBERT A. WOOD.. ,
CK, M.o. (:SH SUPERVISING MECHANICAL-ENGINEER
AC 0 4 5. 9 3 � C�C 2 2 l U A