HomeMy Public PortalAbout5300 ROSEMEAD BLVD_Sewer__ • L
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76A 6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER— NAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 00 Rosemead
COLEMAN W. JENKINS, SUPT. OF BUILDING LOCALITY Temple City
NEAREST
FOR APPLICANT TO FILL IN CR055 ST.
LEGAL
DESCRIPTION LOT NO. OWNERPhil RochenbachsInu.
MAIL
BLOCK TRACTADDRESS 10128 Rush Street
N OF BLDGS.
SIZE OF LOT W ON LOT CITYR. NO. L48-6159
USE OF -y_ DISTRICT NO. GROUP MAP PROC SED BY
BUILDINGS r. ' +Q
p
CONTRACTOR 'Owje[n Bros O Plumbing 9 Inca Q
ADDRESS � 5 North Baldwin Avenue �J C/ CONNECTION DATA
CITY me TEL. NO. .-0078 (, STATION /) / 2__ DEPTH
STATE LICC 6 MANHOLE REFERENCE 61---3 ' UPPER
LICENSE No: 231 741 CLASS
NO. I DESCRIPTION OF WORK FEE TYPE OF CONNECTIONP.L LENGTH FROM
HOUSE SEWER CONNECTING TO `O Y. CURB M.L.TO P.L.
PUBLIC SEWER Cif .700 (�
SEPTIC TANK.SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO'. �� JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO, ROAD PERMIT NO,
PRIVATE DISPOSAL SYSTEM @ $3.00 O
! CONNECT ADDITIONAL BLDG.OR AFFIDAVIT w�lv[R EIISEM[NT RECORD. INSTR.NO. DATE U
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD �
EXTN..CESSPOOL,DRYWELL.MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING U
SEWER OR DISPOSAL SYSTEM W 83.00 STATE ENCROACHMENT d
N
PERMIT NO. �
INDUSTRIAL
WASTE APPROVAL
f)WpNyEryRI'S PERMIT $ Oo CHARGES
' AyqU 1d1 RIZA ION TOTAL FEE D Oe CONNECTION CHARGE FEE )
IHAVEOAT THIS DATE A .CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR'TO-CONNECT THE ABOVE DESC7iIBED EXISTING DWELLING APPROVALS
TO 7HE DPU BLIC SEWER. DA INS �TOR'S T RE
SIGNED`T4HIS DAY OF 19_
OWNER OR NEW HOUSE SEWER -
OWNERS AGENT_ CONNECT ADDITIONAL
�•• BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE TFYAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL C60'NTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL
1 HEREBY CER'oIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM HE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO .DE C IBED ESIDEN PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
M.O. CASH
T4g SUPERVISING MECHANICAL ENGINEER
LA(en6.a -3 qvSJAN 1 1 0 D 1 00C)