HomeMy Public PortalAbout5634-5634 1/2 ROSEMEAD BLVD_Sewer__ .-- ` 5� •� T A � •r� � r � �
EPARTIVUZ1TT OF COUNTY ENGngzm SE �ER—SEWAGE DISPOSAL
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DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES -
13UILDING !�? •dy•f __•.��.' A�
WILLIA FQ)C COIdLIT1r�EN r ER3 ADDRESS ai, -". T "cT�'✓• rfi`4. 3" G
SS i1 LLQ,
FOR APPLICANIR FILL IN LOCALITY
BUILDING' NEAREST
'ADDRESS GROSS ST. amw
LOCALIT ' DIST RI NO. SERIA/L�NO. PERMIT PERMI�TJNO.
NEAREST A J AArMf o _'S - -�9I± p S
CROSS S Z�Q �ftls�a,�!{�
�' CEIVED BY Ready for Inspection DATrE�ISSUED
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OWNER . i_•��ir✓��L/.Il r o~�G /
MAIL USE ZONE OCCUPANCY M"A��
P
ADDRESS BK s
PG
6 w
CITY 3.9 TEL-No-,A'rL
CONTRACTOR CO.IMP.NO.
ADDRESS JOB.NO.
CITY TRUNK PERMIT 0. 1r
.®—STATE
RELEGAL GISTRATION NO. Tow p � it t2J COUNTY, ROAD PERMIT N0. j
DESCRIPTION LOT NO STATE ENCRO�CHM
PERMIT NO. !
BLOCK TRA C , ' j. INDUSTRIAL' \
WASTE APPROVAL
SIZE OF LOT OF BLDGS. HARGESUSE OF �s
J
NOW ON LOT
BUI DG'INGSCONNECTION CHARGE FEE !
NO. DE911RIFT113N OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER a $ 3.50 RECEIPT NO. I T IBY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
ONNECTADDITIONAL BLDG.OR / e9 ®� EXCEPT ON RECO ` D
WORK TO HOUSE SEWER 1.0 +CG N0.
ALTER OR REPAIR EXISTING /
I DATE \ BY
SEWER OR DISPOSAL SYSTEM 1.00 �
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.05 ONNECTION DATA
SEPTIC TANK.SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLEREFERENCEUPPE
LOWER
TYPE gF CONNECTION LENGTH FROM
Y. CURB P.L. M.L.TO P.L.
OWNERS PERMIT ; 00
AUTHORIZATION TOTAL FEE vio
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED'
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING -APPROVALS I NSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS_SzeL DAY NEW HOUSE SEWER
CONNECT ADDITIONAL
OWNER OiD 4 BUILDING OR WORK :) y S,
OWNERS AGENT... ..s_.._._..._:_......_.--.--._. __._.. ._..-.—•-
SEPTIC TANK.SEEP.PIT(S)
ADDRESS............. _....-._. ._----.---------------- ------ ......_...__._._._._. AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ.THIS APPLI- CESSPOOL E] DRYWELL t
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS, ALTER.REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY, ABANDON HOUSE.SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-�
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE � 1 BEEP.PIT(S)[:] CESSPOOLS
OF PERMITTEE... ..�a =- _ ----...__. s----.._.......-__•--•- c
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