HomeMy Public PortalAbout5607 ROSEMEAD BLVD_Sewer__ 75A 6420-CESOB-10-71)� jAjPPLICATION FOR WRMIT
COUNTY OFfLOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRE.S
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FOR APPLICANT TO FILL IN
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DESCRIPTION LOT NO OWNER
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BIZ[ Or LOT N ON LOT CITY TEL NO (J
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BUILDINGS 015TRICT NO GROUP MAI CESSED BY
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ADDRESS 0 Q L 60 0\ —Q CONNECTION DATA
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LICENSE NOi V
NO DESCRIPTION OF W RK F[[ TYPE Or CONNECTION LCN XIROM
NOUS[5EWER CONNECTING TO Y CURB P L M L TOP L
PUBLIC SEWER O fT 00
5ZpTIC LANK SEMPAO[PIT OR 37), PC NO
IITB AND/OR GRAINFIELD B 31000 CO IMP NO JOB NO
HOUSE EWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO d
PRIVATE DISPOSAL SYSTEM 0 5300 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT RMY[[ [u[RUT RECORD INSTR NO OATS V
WORKTO H OUSE SEWER 5300
OVERFLOW SEEPAGE PIT DRAINFIELD C<
EXTN CESSPOOL DRYWELL C 6500 HWy OR R WIDENING O
00
ALTER REPAIR OR ABANDON HOUSE 0
SEWER OR DISPOSAL SYSTEM 0 53STAT[ENCROACHMENT
MANHOLE 0 fT 00 PERMITNO a
INDUSTRIAL h
WASTE APPROVAL Z
CHARGER
OWNER'S PEEMT[ s
AUTHORIZATION TOTAL FEF CONNECTION CHARGE FEE
I HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN HAMM CON REIMBURSEMENT F[[
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC S (. O [ INIP CTOR E SIGNATURE
6
SIGNED THIS DAY F 1D
OWNER OR NEW NOUS[SEWER
fo
OWN[Ri AOCNT (� CONNECT ADDITIONAL
ADDRE56 V \ SUILDINO OR WORN
99
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION S[ITIC TANK SFIR PMS)STAT[ THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR MAINFlLO
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLU Me ENO AND SEWERS CESSPOOL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT 1 AM PROPERLY R[GIST[R® ANO/OR ALTER REPAIR SEWCN OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I Ay THE LEGAL OWNER OF AND INTEND TO 1 DISCONNECT PLUG AND
RESIDE IN THE MO 1S[D RCSIO[ TIAL PROPERTY ABANDON MOYpE EHE CR
SIGNATURE
OF P[RMRTE[ MCKFILL SEPTIC TANKS ❑
S[V PITIS) [I CESSPOOLS
VALIDATION cK M 0 CASH
2 1 9 gkiM - 310 6 15.0 0A-%