HomeMy Public PortalAbout5500 ROSEMEAD BLVD_Sewer__ TeA eAZD-c[eos-lo-n APPLICATIOI, FOR P RMIT _
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDINGPGROUP .Al'
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GITY STEL NO ' / STATION DEPTH
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NO DESCRI I NOF WORK I[[ TYP{OrcONn[RI N "MOTH FROM
HOUSE R{WRR CONNECTING TO /l Y CURB r L AL TOIL
PUBLIC SEWER O $T 00 L J �T PC NO
SEPTIC TANK SEEPAGE PIT 011 CO IMP NO _J
FIVE AND/OR GRAINFIELD O p0 oG }
HOUR[SEWER CON N[CT1NG TO T1UNK PERMIT NO ROAD PERMIT NO 0
PRIVATE DISPOSAL By
O $
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CONNECT ADDITIONAL SLOG OR AFFIDAVIT 1 ENVIE AAggagNT I RECORD INRTR NO DATE
WORK TO HOUSE B[w[R O 63W V
OVERFLOW R[[PA66 PIT GRAINFIELD O
[]TN CESSFOOLDRYW[LL O 8500 HWY OR QT WIDENING
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AUTHORIZATION TOTAL PEE. -- CONNECTION CHARGE F{E
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT IEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING PP ♦p
To THE FU
Bc (�OAT� JI AtpROVALV DA E INSPECTOR[SIGNATURE
SIGNE THIS
OWNER OR NEW HOUSE SEWER
Ow.......MY CONNECT ADDITIONAL
AppRES. BUILDING OR WORK
B{PTIC TANK BEEF PIT(S),
I M[R[.Y ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AN WON GRAINFIELD
AND CTAT[ THAT THE ABOVE It CORR{CT AND AGR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING O
PLUMBING AND SEWERS CESSPOOL ❑ ORYWELL
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LCALIFORMIA
ICENSED AS R.G RY GL[S COUNT AND STAT[ OF SWAG{DISPOSAL SYSTEM
OR AT I [ L[ O N OF
ND TO
ESIDE IN T ASOV TIAL pP DLCONN[CT PLUG AND
,BAMDON HOUi6 R[w[R
IONATURE
OF PCRMTTT[[ BACKFILL i[ILC TANKR ❑
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VALIDATION cR M 0 CASH
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