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Home My Public Portal About5568-5570 ROSEMEAD BLVD_Sewer__ ' E 06 9&E�� APPLICATION FOR PERMIT ~ 1 IiMON OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL Department of CountyragtaaBT t CDDs� DI loos Aa17�s. ADDRESS DG.S.S WM J FOX. COUNTY ENGINEERa,12 131A.,p CAMMATT D GRIFFIN. SUP T OF BUILDING LOCALITY-7eQ OSP FOR APPLICANT TO FILL IN NEAREST I 4 LEGAL CROSS ST / /} DESCRIPTION LOT NO OWNERMNS. BLOCK TRACT,SU r• 6 ADDRE59 - D /� 0 OF BLOTS .7 SIZE OF LOT HOW ON LOT J CITY TEL NO / BBE DI BUILDINGS DISTRICT NO I GROUP MAP BK PG CONTRACTOR �!j G AooaEBs O s^ CONNECTION DATA CITY TEL NO U � s'1-..S S / STATION DEPTH eg REG�SYRATION NO j7 - ❑ COUNTY G MA UPPER REFERENCE LGrM TYPE OF CONNECTION LENGTH FROM B NO DESCRIPTION OF WORK FEE CURB Err M L TO P L HOUSE SEWER CONNECTING TO B PUBLIC SEWER ® $ 9 b0 HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 100 COX WORK TO HOUSE SEWER BLDG OR 1 DO CG IMP NO �37� JO�NO ALTER OR REPAIR EXISTING N -s-EWER OR OISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO V DISCONNECT AND ABANDON SEWE0. AND/OR DISPOSAL SYSTEM 100 !TATE ENCROACHMENT SEPTIC TANK SEEPAGE PIT OR PERMIT MQ PITS AND/OR DRAINFIELD 2 OD INDUSTRIAL CESSPOOL-DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2 00 S CHARGES O�S PERM 00 CONNECTION CHARGE FEE AUMORTLATION I TOTAL FEE O REIMBURSEMENT FEE I HAVE DATENAMED CON TRACTORTTOS CONNECT THEACTED ABOVEWITH DESCRIBEDTHEYEREIN EXISTING DWELLING APPROVALS PATE INSP TOR 8 SIGNATURE TO THE PUBLIC SEWER /,� SIGNED THI O DAY OF ///➢ C,he I9-J_1 NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL ONNERS AGENT BUILDING OR WORK729�A SEPTIC TANK,BEEP, PITS) ,v ADDRES AND/OR DRAINFI ELD 6 Ste` I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION CESSPOOL[:IDRYWELL❑ 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 011 SEWAGE REPAIR DISPOSAL SYSTEM WEROlt LICENSED AS AS REQUIREERTIFY D BY LOS AT I YANGELES PROPERLY COUNTYS AND STATETERED /OF DISCONNECT PLUG AND CALIFORNIA OR THAT I AN THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER DESCRIBED RESIDENTIAL PROPERTY BACKFILL BE C TAHSNKS❑ LEEP PIT 9 C !POOLS SIGNATURE OF PERMITTEE WILLIAM J FOX, COUNTY ENGINEER VALIDATION By i-&1 3"7 8P MARIO a 8.50By p DEPUTY 00p, � /1 DEPUTY By Er ® DEPUTY I DEPUTY o aaE 6 ' D APPLICATION FOR PERIVIIT� " ` s �DraSION OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL Department of CDGntT Englueu RUI _ County °' L0f �� AODRELDISIG a �V� WM J FOX, COUNTY ENGINEER CAYBATT D GRIFFIN CUP T OE BUILDING LOCALITY FOR APPLICANT TO M IN NEAREST CROSS ST LEGAL DESCRIPTION LOT NO I OWNER BLOCK TRACT MAIL ^ NO OF BLDGS ADORESSy 3� 0 /YA« �(D /� / SIZE OF LOT NOW ON LOT CITY TEL NO USE OF BUILDINGS DISTRICT NO GROUP YAP BK PG CONTRACTOR 37 �-- ADDRESS 2 17 0 CONNECTION DATA CITY L, A TEL NO /j/J ij � `ST TION DEPTH o ATE MANHOLE REFERENCE REGISTRATION NO /ZpQ�O ❑ COUNTY UPPER LOWER TYPE OF NECTI ON LENGTH FROM No DESCRIPTION OF WORK FEE r CURB P L Y L To P L HOUSE SEWER CONNECTING TO PUBLIC SEWER ® $ 3 3 HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1 00 CONNECT ADDITIONAL BLDG OR vy r CO IVP NO WORK TO HOUSE SEWER 1 00 h _ ALTER OR REPAIR UISTING SEWER OR DISPOSAL SYSTEM 100 TRUNK PERMIT NO YeADP IT NO DISCONMECT AND ABANDON SEWER b-ATE ENCROACHMENT AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO SEPTIC TANK,SEEPAGE PIT OR y PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL CESSPOOL.DRYWELL -- WASTE APPROVAL SPECIAL CONDITIONS ONLY 2 DO CHARGES CONNECTION C GE FEE OWP ws PERMIT S 00 if AUTHORIZATION TOTAL. FEE QO REIMBURSEMENT FEE I I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EKISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE TO THE PUBLIC SEWER �/ •� SIGNED THIS / b DAY OF 4a 19 , NEW HOUSE SEWER W S OWNEROR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK cr a P4 ADDRESS9HPTIC TANK SEEP PIT(S) ANO/OR DRAINFIELD A ir—, 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ AMD 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 1 HEREBYCERTIFY THAT I AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT 1 AN THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER DESCRIBED RESIDENTIAL PROPERTY BACKFILL DEP CC TANKS❑ SEEP PITS CESSPOOLS SIGNATURE OF PERMITTEE WILLIAM J FOX. COUNTY ENGINEER VALIDATION e7 _ACple¢ 4 2r. fe16� 4 4.00 DEPUTY (� C • � DEPUTY ,BY BY 0 DEPUTY DEPUTY