HomeMy Public PortalAbout5620 ROSEMEAD BLVD_Sewer__ f ,f�
sA6425ir APPLI16ATION F R P
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Ff __
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CLIaNN A. LAMBIE, County Engineer
SATT D. GRIFFIN, Sup t of Building FOR APPLICANT TO PILI. IN
LEGAL
DESCRIPTION t,- ;4 el OWNER
MAI L
BLOCK TRA ' ADDRESS
s+ OF BLDGS.
SIZE OF LOT t_x«e- s- :,-�e.K.f.., OW ON LOT d_ ". ._` CITY. TEL. NO.,
USE OF
BUILDINGS D STRICT NO. GROUP[ MAP PROCESSED BY
` BK PG
CONTRACTOR
ADDRESS — _ CONNECTION DATA -
CITY TEL,N0. STATION / / DEPTH / `
STATE MANHOLE REFERENCE : `
REGISTRATION NO, COUNTY { LOWER
No. DESCRIPTION OF WORK FEE --
HOUSE SEWER CONNECTING TO I _
PUBLIC SEWER �� $9.00 TYPE OF_CONNECTION LENGTH FROM
SEPTIC TANK;SEEPAGE PIT OR Y. CURB P.L. M.L.TO P,L.
PITS AND/OR DRAINFIELD @ $3.00 _ -
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN...CESSP00L. DRYWELL @ $2..00
—� HOUSE SEWER CONNECTING TOP.C•NO,
PRIVATE DISPOSAL SYSTEM @ $1.00 ,0.IMP. NO. __' J03 No.
' CONNECT ADDITIONAL BLDG,OR Y^ --
WORK TO.HOUSE SEWER @ $1.00 TRUNK PERMIT NO, ROAD PERMIT N0.
A! ll' REPAIR 0.R ABANDON HOUSE STATE ENCROACHMENT -
SEWER 6R DiSPD AL SYSTEM to, $1.00 PERMIT N0.
INDUSTRIAL
'NASTE APPROVAL
_ CHARGES
OWNERS PERMIT s 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE1 �,' REIMBURSEMENT FEE
IHAVEDATE A CONTRACT WITH THE HEREIN NMED CON-
TRACTORATO CIONNECT THE ABOVE DESCRIBED EXISTIINGP(DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. —
SIGNED 'HIS .DRY OF 19_.` _NEW HOUSE SEWER
OWNER OR - CONNECT ADDITIONAL
OWNERS AGENT .. BUILDING OR WORK
ADDRESS. SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTE12,REPAIR,SEWER DR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE EWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIk-1, PROPERTY, BACKFILL SEPTIC TANKS ❑
SIGNATURE_
SEEP.PIT(S) ❑ CESSPOOLS El— _
OF PERMITTEE_____.___ " VALIDATION ROBERT A. WOOD
j CK, M.o. CASH SUPERVISING MECHANICAL ENGINEER
e�_J.