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HomeMy Public PortalAbout5402 ROSEMEAD BLVD_Sewer__ DEPARTMENT OF COUNTY ENGINEERSEWER-SEWAGE DISPOSAL 1 DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION F COUNTY OF LOS ANGELES gu I L D I N G WILLIAM J. FOX, COUNTY ENGINEER ADDRESS ��C� X/ S '� © FOR APPLICANT TO FILL IN LOCALITY BUILDING /-/// �+Q�`/ NEAREST ADDRESS � /►�o _5,C1 '�17 �.[.%�a_ CROSS ST. LOCALITYDISTRICT NO. SERIAL NO. PERMIT NO. ���L �j NEAREST A [/ CROSS ST. RE EIVEO+BY Ready for Inspection /DAT ISSU OWNER /aC� � � /LL MAILi/l�,9,� USE ZON OCCUPANCY BK MAP PG ADDRESS (�.7 Jf ��/� // CITY TEL-NO. i/ -, I 2- Y / CONTRACTOR �.�� �/ ���� 4liibf{y�.. G CO.IMP.N0. ADDRESS fJ db j JE y 64 JOB.NO. CITY � C ��a TEL.NO,,477Z;7/2! TRUNK PERMIT NO. REGISTRATION NO. no 7 STATE ROAD PERMIT NO,., LEGAL DESCRIPTION LOT NO. STATE ENCROACHMENT �at .tr?'�. PERMIT NO. i A BLOCK TRACT DUSTRIL WASTE APP �ROVAL /� Z?31 SIZE OF LOTNO.OF BLDGS. ,+ C ES / E NOW ON LOT / � Q , // .✓`� USE OF ��yy i� BUILDINGS,5/�ie_� 9L NO. .' DESCRIPTION OF WORK FEE REIMBURSEMENT FEE HOUSE SEWER CONNECTING TO PUBLICSEWER @ $ 3.50 RECEIPTNO. DATE BY '— HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED WORK TO,HOUSE SEWER 1.00 AL-TER-OWREPAIR EXISTING NO. SEWER OR:DISPOSAL SYSTEM -1.00 DISCONNECT AND ABANDON SEWER AND/OR DISPOSAL SYSTEM 1.00 CONNECTION-DATA SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD 2.00 STATION DEPTH CESSPOOL-DRYWELL i SPECIAL CONDITIONS ONLY 2.00 REFERENCE -,UPPE . 'LOW ERT TYPE OF CONNECTION LENGTH'FROM OWNERS PERMIT $ I 00 AUTHORIZATION I TOTAL FEE I I 1 HAVE THIS DATE CONTRACTED WITH THE HERE N NAMED -� CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVAL INSPECTOR'S SIGNATURE DATE DWELLING TO THE PUBLIC SEWER SIGNED THIS.............-......DAY OF..............._..-.....____-•--19_--- NEW HOUSE SEWER 5 OWNER OR / CON NECT ADDITIONAL . ....._.....r!r! _.._.._. BUILDING OR WORK OWNERS AGENT.......... -------- --..------•- V� SEPTIC TANK,SEEP.PIT(S) ADDRESS----------------------- ------------...-----..........--•---........_....c-....-. AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL(] DRYWELL I] CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERT f THAT I AM/P OPERLY REGISTERED AND/OR LICENSED A )REQU R BY 0 A GELES COUNTY DISCONNECT PLUG AND AND STATE OFC I ORNI TH' T E LE OWN- ABA DON HOUSE SEWER ER OF THE ABW DESC �jR 1 PRO Y. KFILL SEPTIC TANKS ❑ SIGNATURE /p SEEP.PIT(S)o CESSPOOLS ED OF PERMITTE -r - -(------ A. -•••. 76A642A 663 7/53