HomeMy Public PortalAbout5570 ROSEMEAD BLVD_Sewer__ :a asea it BB APPLICATION FOR PERMIT 1
DIVISION OF BUMDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deparbmant of County Engineer
County of Loo; Angela BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
m CASSATTD GRIFFIN SUPTOPBUILDING LOCALITY
FOR APPLICANT TO FELL IN NSM
LEGAL ¢� OWNER
DESCRIPTION LOT NO
MAIL
BLOCK TRACT ADDRESS
N LOGS CITY TEL NO
SIZE OF LOT LOT
USE OF DISTRICT NO GROUP MAP PQ
Bx
CONTRACTOR —5� f Y
ON DATA
ADDRESS CO
CITY TEL NO STAT DEPTH /
MANHOLE EF ENCE
STATE / WER
REGISTRATION NO COUNTY
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE P'COQQLEN6TX FROM
PUBLIC SEWER @ $3 SO CURBENION M L TOP L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFI ELD ® S 3 00
OVERFLOW SEEPAGE PIT GRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE $2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM S 100 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOU BE SEWER ® J 100 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® J 100 WASTE APPROVAL
CHARGES
CONNECTION CHARGEFEE
OWNERS PERMIT s 11 00
AUTHORIZATION TOTAL 1?EE RfIYBURSEYENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA ED COX APPROVALS DATE INSPECT ATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 19— CONNECT ADDITIONAL
OWAG
EF
OR 'lY/�G BUILDING OR WORK
OWNERS ENT �rI.A,T� SEPTIC TANK,SEEP PIT($)
ADDRESS AND/OR GRAINFIELD
I 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
I HEREBY CERTIFY THAT I AM PROPERLY REGIJTERED AND/OR D14CONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT THE LEGAL OWNER F THE ABOVE
DESCRIBED RESIDENTI P PERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PITS ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A LAMBf CouN ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CA ■ D fN
L 4 8 7 5 DEC 54..,WT
TGA 843E CEpU6 JI-Tne APPLICA O FOR P IT
SEWER—SEWAGE DISPOSAL
FOR APPLICANT TO FILL IN DISTRICTKO GROUP SK MAP P e5ED By
SOIL
AooRESe `arj �� OSL�� /
LocALlry C[ CONNECTION DATA
NEAREST STATION DEPTH
CROSS Sr
Q MANHOLE REFERENCE UPPER
OWNER �[,y{�� LOWER
TEP[OF CONNECTION M L TO FROM
MAIL Y CUR• PL ML TORE
ADDRESS
PC NO
CITY TEL NO CO IMP NO .IDB NO
DESCRIPTION LOT NO TRUNK PERMIT NO ROAD PERMIT NO
BLOCK TRACT
AFFIDAVIT RAI[aa 1AaaNIT RECORD INETR NO DAT[
NO OF BLO6b
R
BIZ[ OF LOT NOW ON LOT HWY QRST WIDENING
USC OF � �
BUILD IN06 V ��� STATE ENCROACHMENT
PERMIT NO
CONTRACTOR h co ` INDUSTRIAL
WASTE APPROVAL
AOORl66 � `il t].b j�� CHARGES O
CITY lcosePlmrQ4 TEL NO /y7S CONNECTION CHARGE FEE V
STATE 2_VL 4? `/� EIC —3/ REIMBURSEMENT F[[ Q
LICCNS[ NO r / J / LIC (0
NO DESCRIPTION OF WORK FEE " IS TaTaROVA ()
HOUSE SEWER CONNECTING TO ADATE INSPECTOR W
PUBLIC SEWER C d
6 PTIC LANK SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD 0 CONNECT ADDITIONAL r� r r
HOUR[SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM 0 PEPTIC TANK SEEP PIT(p)
CONNECT ADDITIONAL BLDG OR SEPTICAND/OTANK
GRAS EP
WORK TO HOUSE SEWER 0
ELD
OVERFLOW SEEPAGE PIT DRAINPI[LD CESSPOOL ❑ DRYWILL ❑
E%TN CESSPOOL DRYW[LL In A...L[0
ALTER REPAIR OR ABANDONOUSE ALTER REPAIR SEWER OR
SEWER OR DISPOSAL SYSTEM O SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
���{!�p�i BA CKFILI SCPPIC TANKS ❑
OTY1\LCLAAI ISSLQI)CC Fee ,� SEEP PITIS) ❑ CESSPOOLS
f /�
ICATION
A=ORPLATION TOTAL ME o `� AN ONSTAT[ THAT DTH! ABOVE IS STCORRCCT AND AGREI HAVE READ THISE TOLCOMPLY
I HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON WITH ALL COUNTY ORDINANCES AND STAT! LAWS REGULATING
TRACTOR TO CONNECT THE ABOVE DESCRIBED
[}j)pTINO DWELLING PLU MBINO AND SEWERS
TO THE PUBLIC SEWER 1 HERESY CERTIFY THAT 1 AM PROPERLY REGISTERED AMD/OR
SIGNED THIS DAV OF 19_ LICENSED AS REOUIR[D BY LOS ANOL99 COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TO
OWNER OR RESIDE IN THE ASO DESCR [D RESIDENTIAL P,(i7111�TO
OWN ERB
AGENT ''�2``�y
SIGNATURE
ADDRESS OF PERMRT[C
VALIDATION
CK M O CASH 2 f i 4.00
[ Bi1a005
0225-80