HomeMy Public PortalAbout5602 ROSEMEAD BLVD_Sewer__ C91108 12 eB APPLICATION FOR PERMI
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COUNTY OF, LOB ANGELES SEWER-SEWAGE D SPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDIIE[.
COLEMAN W JENKINS SUPT Of BUILDING GF
Louury
.BAREST
FOR APPLICANT TO FILL IN c[OBt BY
DESCRIPTION
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ADDRESS ` CONNECTION DATA
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PUBLIC SEW" O 65M IS
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ITS ACESSPO L DRYWLD E {1000 CO IMP NO JOB NO
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OVERFLOW SEEPAGE PIT ORAINIICLO 0
QiTN CESSPOOL ORYW[LL MANHOLE O {900 H
ALTER REPAIR OR A0ANDO..OUB[ NWY OR BY WIDENING U
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AUTHORIZATION TOTAL FEE I, CONNECTION CHARGE FEE
1 HAVE AT THIS DAT[ A CONTRACT WITH THE H[R[IN NAMED CON REIMBURSEMENT FEE
TRACTOR TO,CONNCCT THE ABOVE DESCRIBED EXISTING DWELLING TWA
TO THE PUBLIC DENVER A"ROI�)
AL3 DAT[ INSPECTOR S SIONATURC
SIGNED THIS DAY OF 19_
Ow MER oR NEW HOUR[GEW"
OWNERS ARGENT_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SIEPTIC1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICAJOF
AND/OTANK B[IE PITISI
AND STAT[ THAT THE ABOVE IS CORRECT AND AGREE TO CO '+NO/OR MAINFIELO
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULA
PLUMBING AND SEWERS CESSPOOL ❑ DRYW[LL ❑
1 HEREBY CERTIFY THAT 1 AY PROPERLY REOIST[R[D ANALTER REPAIR SQWEROR
LICENSED AS REOU FRED BY LOB ANOL[t COUNTY A STAGXWACC DISPOSAL SYSTEM
CALIFORNIA ON THAT I AM THE LEGAL OWNER OF IN DItCOXN[CT PLUG AND
RESIDE IN THE ABOVE DCSCNI O IDCNTIA P[ A BANDON HOUSE SEWER
SIGMATVRQ pACKIILL t[ IC TANKS ❑
OF P[RMfRC
e[IP PITUI cuproou
VALIDATION JACK R ALLEN
CM M D CASH SUPERVISING MECHANICAL ENGINEER
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