HomeMy Public PortalAbout5328 ROSEMEAD BLVD_Sewer__ CEBOB 1 2
-68 APPLICATION,
L®R PERM'T 642D
76AU
COUNTY'OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING _
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS. SUPT. OF BUILDING v
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST,
LEGAL N �
DESCRIPTION LOT NO.,5', I-3, !' OWNER'
/ MAIL
BLOCK TRACTC, S., � +-/�7_ "113 ADDRESS 1
Qt- NO. OF BLDGS.
SIZE OF LOT Psk NOW ON LOT CITY TEL. NO.
I� USE OF
BUILDINGS d� DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR24
tel, L� P
` '
ADDRESS CONNECTION.DATA
CITY / TEL. NO
STATION / DEPTH
STATE LI UPPER
LICENSE NO: !pL it LAL.1r MANHOLE REFERENCE 2�
NO. 1 DE RIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM /
' HOUSE SEWER CONNECTING TO ^ Y. CURB .L. M.L.TO P.L. '
PUBLIC SEWER $5.00 4� p.C.NO.
SEPTIC TANK,SEEPAGE PIT OR /� i
PITS.AND/OR DRAINFIELD @ $10.00 CO:.IMP.NO. V�� JOB.NO. -
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ 53.00 TRUNK PERMIT NO. ROAD PERMIT NO. CL
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR:NO, DATE C)
WORK TO HOUSE SEWER $3.00 - C..,
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL.MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING U
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACHMENT �
PERMIT NO. fn
INDUSTRIAL
Z
WASTE APPROVAL
OWNERS PERMIT $ 21 00 CHARGES
AUTHORIZATION rTOTAL FEE pe CONNECTION CHARGE FEE
IHAVE AT THIS DATE A .CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO-CONNECT THE ABOVE DESCRIBEQ EXISTING DWELLING
TO THE PUBLIC SEW ��n] ^/, APPROVALS D T INSPEC R'S 51 Tr E
SIGNED THIS DAF '7 �l' )g_/O
OWNER OR r 7— NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK' '
SEPTIC TANK.'SEEP,.PIT(S)
1 HEREBY ACKNOWLEDGE HAT,I AVE READ�THIS APPLICATION AND�OR DRAINFIELD
AND STATE THAT-THE'4ABOVE IS CORRECT AND AGREE TO COMPLY _
WITHALL COUNTY %ORDINANCES AND STATE _LAWS REGULATING
PLUMBING AND SEWERS _-� �`� "T-�}� .�, CESSPOOL'❑) DRYWELL •❑' ,}
I HEREBY CERTIFY THAT I AM`PROPERLY REGISTERED'.AND/OR ALTER_. EPA'IR.SEWER OR
LICENSED AS REOUIRED,,,BY LOS ANGLES COUNTY',ND STATE w0FC SEWAGEIDISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND II NTENDITq n
OR,
` DISCONNECT-PLUG AND'
RESIDE.IN�THE ABOVE`'DESCRIBED ESIDENTIZPRRTY.
- ABANDON MOUSE SEWER
SIGNATURE -OF PERMTTT.E 1 - BACKFILL.SEPTIC:TANKS..❑,;_�..' f y�_.1O _
SEEP.PITIS) ❑ CESSPOOLS ❑( �/
_ - - RETORTION
K. M.O. CASH - JACK R.'ALL,EN
SUPERVISING MECHANICAL ENGINEER
C
3 2 4 4�1 JhM 6 1 � o. 7.0 J
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