HomeMy Public PortalAbout5431 ROSEMEAD BLVD_Sewer__ 5&E-6D83 11.55 AR
8 PLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING J
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR PPLICANT T IL _CROSS sr.
LEGAL ' �° °� OWNER
DESCRIPTION LOT NO. MAIL )
BLOCK TRACT e ..� / ADDRESS 3 J
N0. OF BLDGS. CITY ( • TEL. NO.
SIZE OF LOT }! NOW ON LOT _
USE OF
BUILDINGS DISTRICT NO. GROUP MAP CONTRACTOR „�_� P
CONNECTION DATA
ADDRESS a
STATION %3-74 OG-?C ✓. DEPTH
CITY TEL. NO. UPPER'
MANHOLE REFERENCE
❑ STATE L R
REGISTRATION NO. ❑ COUNTY
No. DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FROM
HOUSE�.. PUBLIC E WEER CONNECTING TO @ $3.50 Y. CURB rP.L. M.L. TO P.L. n
SEPTIC TANK,SEEPAGE PIT OR
---PITS AND/OR DRAINFIELD Q $3.00 �-y
OVERFLOW SEEPAGE PIT,DRAINFIELD CO. IMP. NO. /� / , • JOB NO
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $ 2.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Qi $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR P" STATE ENCROACHMENT
WORK TO HOUSE SEWER a $1.00 PERMIT NO.
.ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM n $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ t o0
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE h
I HAVE AT THIS DATE-A CONTRACT WITH THE HEREIN NAMED CON= APPROVALS DATE INS CTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER ✓ &E'.RL
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS - AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1ICHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL
LiAi SEEP. SESEPTIC
TANKS
[I /2' c
SIGNATURE
OF PERMITTEE
JOHN A. LAMBIE,COUNTY tNGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. M. 0. CASH "
TACO 5 3 8 5 DEC 2'7 4 4.50 M
5-65
76A645-65
APPLICATION FOR PERMIT
7 6A 64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /
JOHN A. LAMBIE. County Engineer ADDRESS ( y
COLEMAN W. 11,NKINS, Sup't. of Building
LOCALITY /
NEAREST �� �
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. U/e OWNER
MAIL Ll
BLOCK TRACT ! .� �/ ADDRESS
NO. OF BLDGS. ` /
SIZE OF LOT NOW ON LOT CITY TE NO. J
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
CONTRACTOR BK
ADDRESS 2 �/ / CONNNECTION DATA
CITY /. STATION �J DEPTH
TEL. NO.
LICENSEr$W LLACENSE
IU E
NO. CSS MANHOLE REFERENCE
NO. 1 DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB M.L.TO P.L.
PUBLIC SEWER @ $ 5.00
7+� P.C.NO.
SEPTIC TANK, SEEPAGE PIT OR </i JOB NO.
PITS AND/OR DRAINFIELD C $1 0.00 CO.IMP. NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM C $ 3.00
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. DATE
RK TO HOUSE SEWER C $ 3.00 O
ABANDON HOUSE
SEW ER !R-B19PC9M_ SYSTEM C $ 3.00 Com' q
HWY.OR ST.WIDENING
EXTN.,CESSPOOL, MANHOLE C' $ 5.00
STATE ENCROACHMENT y
I PERCOLATION TEST C $ 5.00 PERMIT NO. 6•
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 3 2 Oo
AUTHORIZATION TOTAL FEE QO CONNECTION CHARGE FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXI TING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS / DAY OF / 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
J� CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(S)
1 HERE B ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY 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 I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND i
RESIDE IN, THE ABO DESCRIBE RES TIAL PROPERTY. ABANDON HOUSE SEWER y�
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP.PIT(S) El CESSPOOLS
�LIDATIONM..11O.. CASH
rig4 8 9 o"a SE-P22 1 0 0 5.00