HomeMy Public PortalAbout5611-5617-5623-5629-5633 ROSEMEAD BLVD_Sewer__ 76A 642D - CE808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL u
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FCRO .
.
FOR APPLICANT TO FILL IN {.
LEGAL
DESC RIPTION LOT NO. N OWNER ;
_ MAIL _
BLOCK TRACT %`�� t' I'"- ADDRESS .- 2 - " - 3
NO, OF SLOGS.
SIZE OF LOT NOW ON LOT CITY'�✓')«.)C obi',Ca1 0. 1) TEL. NO,
USEOFT�f—
BUILDINGS L ., -'� M1 DISTRI CT NO- GROUP MAP PROCESSED BY
��. -- BK PG
&ONTRACTOR
ADDRESS r ` 4r? 1 `° CONNECTION DATA
CITY � - STATION -"'. DEPTH
7 d9 # L,t g„ TEL. NO_ .2 k
STATE J LIC MANHOLE REFERENCE a W i �PPER
LICENSE Nd, GLASS �.,.� .1IC1WsR
No. I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO - Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER $7-OC- -
`,_.
,: P.C.NO
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR ORAINFIELD @ x10:00 CO.IMP.NO.
HOUSE.SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL-BLDG.OR AFFIDAVIT wAiYER EAEEME)IT RECORD.INSTR.NO. DATE. �.
WORK TO HOUSE SEWER @ $3.00 p�
OVERFLOW SEEPAGE PIT.DRAINFIELD C)
EXTN-CESSPOOL.DRY WELL. $5,00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM $3.00
----- — - STATE ENCROACHMENT �--
MANHOLE $7.00 PERMIT NO. W
_---- -- INDUSTRIAL d
WASTE APPROVAL
CHARGES
OWNER'S PERMIT a
AUTHORIZATION TOTAL FEE t , f CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SE��,W, ER�..��G* / " r� IN'F APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THISiL DAY 0 IV
OWNER ORIF `Y NEW HOUSE SEWER -
OWNERS AGE / '�- '" """"'"5'""'� CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS Z�.�. _-rR � J A.� •�' � }
SEPTIC TANK,SEEP,PIT(S)
i H€RESY ACKNOWLEDGE THAT I H6 E READ THIS APPLICATION AND/OR ORAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY ---____—
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYWELL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.$EWER pR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCPN IA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HE SEWER
SIGNATURE - BACKFILLSEPTIC TANKS ElOF PER MT77EE, PIT IS) FlCESSPOOLS ❑
VALIDATION CK. M.0. CASH
2 Oi`APR �—'O 1 6 0 � 5.0 V ,&-.;