HomeMy Public PortalAbout5322 ROSEMEAD BLVD_Sewer__ ES08-8.58 !
Ceaoa• ® LIC^ ' N FOR PE0 ! ®.MI �.
COUNTY OF LOS ANGELES
SEWER-SEWAGE ®ISP®SAI..
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE. County Engineer �yy
CASSATT D. GRIFFIN, Supt of Building LOCALITY (C�
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. /
DESCRIPTION TION LOT NO. (/� e 5-0 / OWNER
BLOCK " A�T ® MAIL
ADDRESS
NO.OF BLDGt.
SIZE OF LOT NOW ON LOT CITY TEL.N0.
USE OF
BUILDINGS ol DISTRICT NO. GROUP MAP I TPROCESSED BY
BK PG
CONTRACTOR'
ADDRESS ® �� v CONNECTION DATA
CITY TEL.N0. 6d STATION DEPTH
ATE MANHOLE REFERENCE . UPPER
REGISTRATION NO. COUNTY LOWER
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO �)
PUBLIC SEWER @ $3.00 ✓ TYPE OF CONNECT6pk LdftTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. W.L.TO P.L.
ITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER P.C NO.
PRIVATE DISPOSAL SYSTEM CONNEC�ING TO @ $1.00 CO.IMP.NO. pQ -JOB No.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE QQ REIMBURSEMENT FEE
I CT
HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPEO 1GNATURE
TRACTOR TO CONNECT 7 E ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SpfR I -Y
SIGNED THIS AY OF 19 NEW HOUSE SEWER
OWNER ORCONNECT ADDITIONAL
OWNERSAGENT BUILDING OR WORK
SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLE GE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL[I 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 ANGOMS r—UNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE BOVE ABANDON HOUSE SEWER
DESCRIBED RESIDE IP TY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PITS) E] CESSPOOLS 1:1 /LT nJ t,.,,..;c('�
OF PERMITTE 5-3ta i4 ._—,cQ.�da.
�P �LIROBERT WOOD
eg„ M,.0. "it SUPERVISING MECHANICAL ENGINEER
5 6' 5 9',,—., 'AN' 2 4 1 v A 5.G 0