HomeMy Public PortalAbout5628-5628 1/2-5632-5632 1/2 ROSEMEAD BLVD_Sewer__ E-66s 1d•55 `''
& APPLICATIONOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING -•f _ f ,� /vi g;_'.-;�
.JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS_ 1:.',.-✓�"_�_ y 5 r�s:_yj,..:.
PD CASSATT D. GRIFFIN, SUP'T-OF BUILDING
LOG.ALiTY
FOR APPLICANT TO FILL IN NEAREST
LEGAL $- -• T —
DESCRIPTION LOT NO. '' OWNER
BLOCK - TRACT Z. r _ V
MAIL -- --
i,c :a•._ 1C-r�r. !• ADDRESS."
DDRiSS 1`
-ted d_ 1 I✓ a a.� JS'd.! --r `
i Ntl. OF BLDG S. ;N. —
SIZE OF LOT S t NOW ON LOT CITY` .Mi pti TEL, N0,
USE
CONTR'LOACTOR. y �• .z DISTRICT NO. GROUP MAP
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-- _ ._ a - - 3 SK PG
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ADDRESS
C01 CTIOX DATA
STATION DEPTH
'CITY TEL. NO. — --------- — --^— _
MANHOLE REFERENCE UPPER
STATE �LOWER
REGISTRATION NO. �r -Z' 11 COUNTY / A —
l'/',fes
NO. ' --DESCRIPTION OF WORK FEE
HOUSE SELLER CANNECTING TO T i-- TYPE OF CONNECTION LENGTH FROM
Y. CURB P.L. M.L.TO P.L.
P U B
LIC S EN t d_ _ $ - --------_—._-
SEPTIC TANK,SEEPAGE PIT OR --�--!_
-� PITS AND/OR DRAINFIELD () $ .00 --- -----. .-- .,._.� ._ -_•..
OVERFLOW SEEPAGE PIT, DRAINFIELD "..,, P NO.
J EXTN.,CESSPOOL,DRYNELL,MANHOLE @' $ :00 CO. IMP NO + _308
- _.__-...- ___..-b- --
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q5 $ .0,1 TRUNK PERMIT NO .�' ROAD PERMIT NO,
/ CONNECT ADDITIONAL SLOG.OR 9 STATE ENCROACHMENT.- �
f _ WORK TO HOUSE SEWER _ _ (t $ 00 -
y --- ----- -- -=-� -- --
��
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER Old DISPOSAL SYS'T'EM---- $-.00 ----�---_ WASTE A.PPR.OtiAi..
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 00
AUTHORIZATION TOTAL FEE - REIMBURSEMENT FEE
r.:
I-HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE, IINSPECTOR'SSICNATURE
TRACTOR TO CONNECT THE ABOVE DF,SCRIRED EXISTING 5!`IELL,[NG ;�..
TO THE PUBLIC SEWER. - -- - NEW HOUSE SEWER -(
SIGNED THIS-L,_-_-DAY OF rza.-_._ I9�.�' CONNECT ADDITIONAL I I
OWNER OR BUILDING CR WORK _
OWNERS AGENT r - s t _._ -- ---- ` ----.r> .---' -----'-----
-'fi" y SEPTIC TANK,SEEP PITS)
ADDRESSr'' r- - r �- ? 'j>�.;"-t - AND,/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STALE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL G ORfNELL_� ,
WITH ALL COUN'T'Y ORDINANCES AND STATE LAWS REGULATINGALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS.
SEWAG£DISPOSAL SYSTEM
DI
HERESY CERTIFY THAT I. AM PROPERLY REGISTERED AND/OR
LICENSED AS P.EQUIRED B';' LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEaA OWNER OF THE ABOVE. _ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL,PROPERTY ,% BACKFILL SEPTIC TANKS{_j
r• _' 3 SEEP.PIT(S) Ll CESSPOOLS J
SIGNATURE -----------
OF PERMITTEE.' ----
IOHN A. LAMBIE, COUNTY ENGINEER !f VALIDATION ROBERT A.WOOD,CI-4IEF PLBG. INSPECTOR
CASH