HomeMy Public PortalAbout5644 ROSEMEAD BLVD_Sewer__ GhE4ti^ APPLICATION -OR PERMIT 7
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DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Eaglneer
County of Los Angeles BUILDING t
WM.J.FOX,COUNTY ENGINEER ADDRESS"
CASSATT D.GRIFFIN,SUPIT OF BUILDING -LOCALITY g, I -�_ -
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FOR APPLICANT TO FILL IN VxEARES ;
CROSS Si. -` -
LEGAL ?f
-DESCRIPTION�LOT_NO.� P°.. _ _OWNER
BLOCK TRACT MAIL ^`� a►_/"
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-ADDRESS 't �1`1{p"-s� ,ili''. ;s''. `�'. ,. ,.
SIZE OF LOT NOWNO OON$LOTS _ CITY �y &'A f _
'--p-- --- (0''��'ge" _ TEL. NO. ,+
USE OF '`'I k/��'' ,r
_BUILUINGS ..+(' � 'd _.e r» f '
_ �% DISTRICT NO., � GROUP � MAP
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CONTRACTOR Y`` .six 4�' rt '..�" .If.. • 1
ADDRESS = - — CONNECTION DATA - ----
CITY _ ,. TEL. NO. STATION_ -v-.---.----.`. DEPTH --.-----
, "`STAT€
MANHOLE REFERENCE
REGISTRATION NO, VV ER
NO. DESCRIPTION OF WORK FEE
- TYPE yr Cl :NECT=ON- LENGTH FROM
IfOJ E SEWER CONNcCTING- 'Y. CU'26 L N_TH FR
PUBLIC SEWER �'x $_3.50l�__
HOUSE$MYER CONNECTING 0
PRIVAT_-D DISPOSAL SY EM 1,00_,_
1 CONNECT ADDITIONAL 8L OR I P C N0. 1
WORK TO LOUSE_SEWER 1_00
-�
ALTER OR REPAIR EXIS!'!NG
* E:R OR
DISPOSAL SYSTEM 1,00TRUNK PERMIT NO. ROAD PERMIT NO.
'--s -- — ---- _
DISCONNF T AND APANDON SEWER TF — -- —_� —
AND/OR DISPOSAL T'1ENCROACHMENT
_OSAL SYSTEM I.CO _ STATE NCO.. -
-� SEPTIC TANK. SELrAGE PIT OR ---- ----- '-----'---. --- - -
PIT_S_AND/OR DRAINFIELD 2.0_0 `INDUSTRIAL
CESSPOOL UP,YWELL. —� -_WASTE APPROVAL
SPEC�[A! CGN DITIONS ONLY 2,01} -�_ -- --- CHARGES
- - ------ -- CHARG ES
-'�--� - CONNECTION CHARGE FEE
OWNEWS -]—PERMIT
AUTHORIZATION I TOTAL FEE � �- -- REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CON-NF.CT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS ALS DATE INSPECTORS SIGNATURE
TO IHE PUBLIC SEWER -- ---` - ----
.3 r NEW HOUSE SEWER
S1GP ED T}i's _ ,'II�DAY OF __�.9�_ ------ _ p
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _ ' _BUILDING OR WORK—_
SEPTIC TANK, SEEP,PIT(S)
ADDRESS '2
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 'CESSPOOL 0 DRYWELL 0
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING -glTER. REPAIR,"EWER OR
PLUMBING AND SE`,VEkS° SEWAGE DISPOSAL SYSTEM
I HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR. - V------- -
LICENSED AS P.EO'JERED BY LOS ANGELES COUNTY. -ND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL---OWN" OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. IC NK'❑ _ I
Z' .�.. SEEP PIT( S)SEPTACKFILL CESSPOOLS
SIGNATURE ', ' .P,.::{� •d,... - '-_-_-..._e....._ -"-- __.__�-,.
OF PERMITTED `'"� � -
WIL;LIAM J.FOX,COUNTY ENGINEER ALIDATION R.A.WOOD.C.I"IIEF PLBG. INSPECTOR