HomeMy Public PortalAbout5132 ROSEMEAD BLVD_Sewer__ APPLICATION FOR PERMIT
ceaoe-e-ss COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING O ,
e 0A
JOHN A. LAMBIE, County Engineer AD60
DRESS
CASSATT D. GRIFFIN, Sup't of Building LOCALITY �.
FOR APPLICANT TO FILL IN NEAREST
T.
7
CROSS ST.
LEGAL C*4 401 .p
+ DESCRIPTION LOT N0. OWNER
K 0 r jTDC* —3MAIL
d? /✓ ADDRESS
NO.OF BLDGS.
IZE OF LOT :3 NOW ON LOT ` CITY TEL NO.
USE OF
BUILDINGS DISTRICT NO. GROUP BK PG MAP PROCESSED BY
CONTRACTOR 46elery
ADDRESS �_ I„ �„ CONNECTION TA
CITY % )1, // TEELL.NO. 3�T� STATION �p gj DEPTH
ATE REGISTRATION NO. (p 7 l / �❑ COUNTY MANHOLE REFERENCE PPER
NO. DESCRIPTION OF WORK FEE LOW
HOUSE SEWER CONNECTING TO -
PUBLIC SEWER @ $5.00 C C7
�TYPE OF CONNECTION LENGTH FROM e�-r
SEPTIC TANK, SEEPAGE PIT OR L'Y. L CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00 _ '
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN„CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB N0.
CONNECT ADDITIONAL BLDG.OR
WORTO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
ALTEK
SEWER OR OREPAIR SYSTEM ABANDON HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 OC CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE d 4) 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.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER -i
OWNER OR n P CONNECT ADDITIONAL
OWNERS AGENT Q� BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
ADDRESS 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 t THE LE�GAOWNER OF THE ABOVE
DESCRIBED RESIDEN IAL OPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PIT(S) [I CESSPOOLS❑
.
OF PERMITT
OF ROBERT A.WOOD
tVALIDATION
M.o. CASH SUPERVISING MECHANICAL ENGINEER
UAC0 6 0 7 5- fr? g 1 v A 5.00 V; :.