HomeMy Public PortalAbout5585 ROSEMEAD BLVD_Sewer__ CEBDBA4/TP APPLICATION OR PERMI
TSA642L COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY
FOR APPLICANT TO FILL IN N[AR[ir
cnoes er
LEGAL
DESCRIPTION LOT NO 27-- OWNER
MAIL
[LOCK TRACT -23 ADDRESS
NO OF BLOOb
SIZE OF LOT NOW ON LOT CITY TEL NO
06E OF DISTRICT NO GROUP MAP C[BSED BY
BUILDINGS BE PS
CONTRACTOR 6, 0 6
[ 0S F C
ADDRESS CONNECTION DATA
CITY TAI / TEL XO .E STATION DEPTH
LICENSE NO Y CLA84J�IJ MANHOLE REFERENCE 670.0 O \ LOWER
NO DESCRIPTION O WORK FEE TYPE OF CONNECTION LENGTH FROM
NOUS[6CWEfl CONNECTING TO Y CURB ML TOR L
RUBLICSBWER
6 RFIC ANK SEEPAGE PIT Ofl P C NOT.
RITB AND/OR ORAINPI6LD m CO NMR NO JOB NO ` `,` J' O
HOUSE SEWER CONNECTING TO TRUNK R[RNIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM Y
CONNECT ADDI TIONAL ELOO OR AFFIDAVIT S.Iv q.[uR RECORD INBTR NO DAT[ O
WORK TO HOUSE S[WCR 0
OVERFLOW SEEPAGE PIT DRAINFIELD
XXTN CESSPOOL ORYWELL MANHOLE
ALTER REPAIR OR ABANDON HOUBC HWY OR ST WIDENING a
SEWER OR DISPOSAL SYSTEM Q BTR[ENCROACHMENT y
Z
PERMIT NO
INDUSTRIAL
��[E}�p WASTE APPROVAL
OTTITws PEANII7 s CHARGED
AUTHORIZATION TOTAL FEE CONNECTION CHARGE 16C
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COX REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I�}S}Sp
TO THE PC'LIC SEWER APPROVAL DATE INSPECTOR B SIGNATURE
SIGNED THIS_y_D�yY {�FIY_
OWNER OR 7///A/�t NEW HOUSE SEWER
OW NlR6 AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PITIBI
I H[RCBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE 1E CORRECT AN AORBE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND 8[W[R5 CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF 6EWXGE DIST05/1 SYSTEM
CALIFORNIA OR THA 1 AM [ L L OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ADO C D[ IBC [BIDENTI PROPER Y ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKi ❑
OF PCRM"re! 'A 6E[P PIT 161 ❑
CESSPOOLS
�R�LIDATION
CK M 0 CASH
"l 9 4fiJk c5 1 O A-
m I.6�