HomeMy Public PortalAbout5646-5648-5650-5652-5654-5656 ROSEMEAD BLVD_Sewer__ 7c,Av
`EAPPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP BK PG MAP PROCESSED BY
BUILDING y
ADDRESS ` �7 ) -j �.-p op-
�p h / CONNECTION DATA
LOCALITY �L�y l� �J � y
NEAREST // /� �y ,�yJy STATION �'��"'� P„J�V
CROSS ST. f..- V i
PPER
MANHOLE REFERENCE ' �'-` .-�+ LOWER
OWNER TYPE OF CONNECTION LENGTH FROM
MAI Y, CURB P.L. M.L.TO P.L.
ADD
P.C.NO.
CO.IMP.NO. JOB NO.
CITY TEL.NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERM IT NO.
.:'j f? INDUSTRIAL
CONTRACTO
WASTE APPROVAL
ADDR 55CHARGES
1.
f/ CONNECTION CHARGE FEE
CITY TEL.NO. `
STAT e LIC A REIM 13URSEMENT FEE
LICENSE NO CLASS O
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTORS SIGNATURE v
HOUSE SEWER CONNECTING TO � IN
E PUBLIC SEWER O
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER
PITS ANDi OR DRAINFIELD CONNECT ADDITIONAL W
HOUSE SEWER CONNECTING TO BUILDING OR WORK {{{{YYYY
PRIVATE DISPOSAL SYSTEM d'
CONNECT ADDITIONAL BLDGAND/OR GRAINFIELD.OR SEPTIC TANK,SEEP.PITS) '
WORK TO HOUSE SEWER z
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL 7jDRYWELL❑
EXTN.,CESSPOOL,DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS
SEEP.PIT(5)❑ CESSPOOLS El
OWNER'S Permit s
AUTHORIZATION I TOTAL FEES VALIDATION
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_
OWNER OR
OWNERS AGENT
ADDRESS
1HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY R r
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLU M BING AND SEWERS.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR 444TIIIn `'
LICENSED AS REQUIR D BY LOS ANGELES COUNTY AND STATE OF O.J
CALIFORNIA OR THAT AM THE LEGAL OWNER OF. D INTEND TO RE- ,
SIDE IN,THE ABOVE SCRIBED RESIDENTIAL P PER"
SIGNATURE !f {
OF PERM117wxF-!!! `��