HomeMy Public PortalAbout5595 ROSEMEAD BLVD_Sewer__ 76A EAYO-CE608-10-71
APPLICATION OR PERMIT ILII
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION B
UILDING
FOR APPLICANT TO FILL IN
y
LEGALOIL
D65CRIPTION LOT NO OWNER
BLOCK TRACT NO OF BLOTSIZE OF LOT NOW ONlOT z TEL NO
USE 01 Y'w y DISTRICTNO ORO PO
MAP SSED BY
BUILDINGS
BR
CONTRACTOR L`�
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AODR... 7/ CONNECTION DATA
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CITY Lj' TEL NO STATION �J
{TAT[ � J CIC`{{� MANHOLIREFERENCE 3 tY3 .s,d
LICENSE NO �J
MO DESC IPTIGN 0-F WORK F[[ TYPE OR CONNECTION LCNG H FROM
HOUSE S[WLR CONNECTING TO CURB p L ML TOP L
PUBLIC SEWER O $700
SEPTIC TANK SEEPAGE PIT M PC
PITS AND/OR GRAINFIELD Q slow CO IMP NO JOB NOpC 'S—
HOUSE{EWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO d
PRI VAT!DISPOSAL SYSTEM O ES 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT {MTv TuuTRl RECOROD INSTR NOS DAT[ 0
WORK TO HOUSE SEWER O {S 00
OVERFLOW SEEPAGE PIT GRAINFIELD D[
LZTN CESSPOOL DRYWILL O [S OO HWY OR BT WIDENING ALTER REPAIR OR ABANDON HOUi
SEWER
OR DISPOSAL SYSTEM C {i 00 STAT!ENCROACHMENT
MANHOLE . $7 00 PERMIT NO a
INDUSTRIAL IA
���T�� WASTE APPROVAL Z
OwNL[L,s PERMT s CHARGES
AUTHORIZATION TOTAL FEE •� ,� COXHECTIDN CHARGE FEE
I HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT F[[
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUSLIC SEWER DATE INSPECTOR{SIGNATURE
SIGNED THIS DAY OF IG_ � '�
OWNER OR NEW NOUS[SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND/OR
TANK {FIE PIT IS)
AND STATE THAT THE ABOVE 16 CORRECT AND AGREE TO COMPLYAXO/OR MAINIICLO
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ ORYWELL I]
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/ORALTER REPAIR SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY ANWSTATE OFSEWAGE DISPOSAL SYSTEM
ULIFORMIA OF THAT AM HL LE.AL OWNER OF AND INTEND TOOIpCONNCCT PLUG AND
RESIDE IN T" RE
A C B RES [H OFF
HOUSE SEWER
816NATD RL
OF PER MITT {� BACRF ILL SEPTIC TANKS ❑
e[eP PIT(B) ❑ CESSPOOLS
VALIDATION cX M 0 CASH
08la,L 19.10 0 1 5.00
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TeA aszD -ceeoe -Io-nl APPLICATI FORE PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER [�pp
BUILDING AND SAFETY DIVISION /ADDRESS S.S/_rA OS
LocwLrry t (�/
FOR APPLICANU� —T�
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D[/CRII(ION LOT NO OWNER
MAIL /
BLOCK TRACT AILADDRESS
e1zE of LOT ON clrY Q TEL no
ueC OP DISTRICT NO GROUP MAP [RSED BY
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•Doq[/// CONNECTION DATA
CITYAC,Q TEL NO y��� STATION ��� DEPTH
STATE LIC MANHOLE REFERENCE
UPPER
LICENSE NO CLA//
NO DESCR ION OF-VVCfRK F[[ I TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CUR[ P L M L TO P L -.
PUBLIC SEWER 0 fT DO
9[PTIC TANK SEEPAGE PIT ORP —_3
PITS AND/OR GRAINFIELD 0 11000 CO IMP NO JOS O
HOU96 SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO D.
PRIVATE DISPOSAL SYSTEM 0 SS 00 O
CONNECT ADDITION AL SLOG OR AFFIDAVIT R4TTT InTIRTYT RECORD INS" NO DAT[ 0
WORK TO HOUSE SEWER 0 $a 00
OVERFLOW SEEPAGE PIT DRAINFI[LD O[
iXTN CESSPOOL ORYW[LL 0 SSoo HWY ORST WIDENING G
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM 0 $a OO STATE ENCROACHMENT W
MANHOLE 0 $T OO PERMIT NO y
INDUSTRIAL
��T��� WAST[APPROVAL I
OWNER'S PERbuT f CHARGES
AUTHORIZATION TOTAL FEE / CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT F[(
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROT A�
TO
THE To CONNECT
SEWER 1 • DAT[ INSPECTOPSfIONATUR[
SIGNED THIS DAV OF I9_
OWNER OR NEW HOUSE 9EWCR
OWNCR6 AGENT CONNECT ADDITIONAL
/UILDINO OR WORK
ADDRESS
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION A.D/OePTICTANX SSCP PITIp)
ANO/OR DRAINFICLD
AND STATE THAT THE ABOVE IS CO
PR[CT AND AOR C[ To COMPLY
WITH ALL COUNTY ORDINANCES AND STAT[ LAW/ REGULATING ❑
FLU MSI NO AND 9EWERS CESSPOOL ❑ DRYWELL
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SLWCR OR
LICENSED AS REQUIRED /Y LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEO L OWNER OF AND INTEND TO DISCONNECT PLUG AND
REBID[ IN THE ABO R ED SIDE TIAL P PERTY ABANDON HOUSE S[W ER
6101 APC MTTTL SACNFi LL SEPTIC TANKS ❑
SEEP PITIm ❑ CX6BPGOLe
VALIDATION - 0 CASH
082 % 1910 0 1 5A0 •