HomeMy Public PortalAbout5605 ROSEMEAD BLVD_Sewer__ TBA 642D CESOQ�CIOTI 1
APPUCATI FOR PCT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING0.43� L C14 40 ADDRESS �/
LOCALITY
FOR APPLICANT TO FILL IN
A G
DESCRIPTION LOT NO OWNIR
MAIL
BLOCK TRACT ADORCSB
NO OF SLOGSO
SIZE OF LOT NOW ON LOT PTY TEL NO
USE OF
BUILDINGS DISTRICT NO 9pOUR MAP PR E!!EO BY
BK PO
CONTRACTOR / O PO O ,5,'08 F �/
ADOpeeB rp Loa/f mcgi, n CONNECTIONDATA
CITY L [� on T[L NO G -Z (. STATION /hP DEPTH
LIC MSC NO
' OL Si MANHOIEREFERCNC[ 43 69 y' LLoow..
Mo DSTATE
ESCRIPTION OF WORK F![ TYPE OF CONNECTION LENGTH FROM
HOUBE SEWER CONNECTING TO Y CUR/ PL ML TOP L
PU SLICSEWER O $T 00
8 PTIC TANK BC[RAOE PIT OR 13 7 P C NO
PIT.AND/OR DRAINFIILD 0 910 OO CO IMP NO JOS NO
HOUSE 86WEF CONN[CTINO TO TRUNK PERMIT NO ROAD PERMIT NO a
PRIVATE DISPOSAL SYSTEM 0 9100 O
C O NNLCT ADDITIONAL BLDG OR AFFIDAVIT ITMYfL LM..... RECORD INSTR MO OhT[ V
WORK TO HOUSE S[W[R 0 93 O0
OVERFLOW SEEPAGE PIT DRAINFICLD O
EXTN CESSPOOL DRYW[LL 0 E!00
R
ALTEREPAIR OR ABANDON HOUSE HWY OR ST WIDENING L.
SEWER OR DISPOSAL SYSTEM 0 [!00 STATE ENCROACHMENT tS,j
MANHOLE 0 fT 00 PERMIT NO O.
INDUSTRIAL N
WASTE APPROVAL
CHARO[i
PEMIT
f
AUTHOEMnON rorAL FEE CONNECTION CHARGE FEE '$�6 CCAS Awy LL
I HAVE AT THIS DATE A CONTRACT WITH THE H[REIM NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE D[BCRIS E[ISTINO DWELLING I�}�TlnJ
TO THE PUBLIC S! /E/R �j� A"ROVALS DATE INSPECTOR 9 SIGNATURE
SIGNED THis-W AY F 1.
OWNER OR NEW HOUSE BOWER y'lp
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEER PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY '!ND/OR GRAINFIELD
WITH ALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
ID
CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TO OISCONNBCT PLUG AND
RE81O1 IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE ❑
OF PERMMEE BACK P ILL SEPTIC TANKS
SLOP PIT(B) ❑ CESSPOOLS
VALIDATION CK M 0 CASH
3 4 71l-,M 10 10 D 15.0 0 "
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