HomeMy Public PortalAbout5676 ROSEMEAD BLVD_Sewer__ .68083-52
5A542D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONUILDING
JOHN A. LAMBIE, COUNTY ENGINEE:=Jc-"")ss
DDRESS < I
COLEMAN W. JENKINS. SUPT. OF BUILIN
OCALITY
EAREST
—f
FOR APPLICANT TO FILL IN ST: -
LEGAL
LOT NO, � OWNER mxv.��
MAIL
BLOCK _ TRACT 4 / _ ADDRESS___
-
_-- _ ---_ NO. OF BLD-GLS. .__..—
SIZE OF LOT NOW ON LOT CITY TEL, NO.
USE OF
BUILDINGS_- -�l Of'�6 DISTRICT NO.. p
GROUP MAP PROCESSE .BY
SK PIG
CONTRACTOR
-- tt `'. ,�a.!RV's'6 �'•e�J_"S, ___._ '..'..1 `., f P. �'_�y t'C. 4, _..�'.
ADDREss 5 tf�f CONNECTION DATA
CITY ] '�{ f+r1rC TEL. NO. " STATION _._ s "� e DEPTH 4
_
STATE LIC / — -- yEj UPPER
LICENSE NO, '&" T— CLASS . lr' MANHOLE REFERENCE
� _ _
No.� .DESCRIPTION OF WORK _ FEE TYPE OFCONNECTION� "a LENGTH F OM
HOU5£SEW ER CONN EG7ING TO Y. CURB G P L M.L.TO P _
PUBLIC SEWER * $5.00 _. 1 � - 0-
--_. — P.C.NO- 0
SEPTIC TANK SEEPAGE PIT OR j 'a!
PITS AND/OR DRAINFIELD @ $10.00 _ , CO. IMP_NO._ �,(g JOB NO. lad
!HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $3.00 TRUNK PERMIT NO, ROAD PERMIT NO.
I ®�
CONNECT ADDITIONAL BLDG OR :AFFIDAVIT WAIVER EAs[IV ENT RECORD. INSTR.'NO.
WORK TO HOUSE SEWER - ;$3.00 —
OVERFLOW SEEPAGE PIT,DRAINFIELD ! ( �`� .__ Lu
a
1EXTN.,CESSPOOL.DRYWELL.MANHOLE 0 $5.00
.__._. ___-- -___.—_..-.___—.__ __ HWY.OR..ST.WIDENING N
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM _ @' $3.00 - STATE ENCROACHMENT
i I PERMIT NO.
--- -�--- INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $i 2 00 _-CHARGES
AUTHORIZATION TOTAL. FEE �- CONNECTION CHARGE FEE
I HAVEAT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON" REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING D T
APPROVALS --T-T
TO THE PUBLIC SEWER. E. INS CTOR' IGNATURE
SIGNED THIS DAY OF 19� --�
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
BU ILDINGOR WORK
ADDRESS
SEPTIC TANK,SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY .--.- --
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR j
LICENSED ASREQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE-LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVECRiSEr ESIDEWrxT �7 PR PERTY.
'�RABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ElOF PER MTTTEE �.-' �`'"'i"1^` =— SEEP.PIT IS) ❑ CESSPOOLS ❑�
?7".,.-VALIDATION JACK R. ALLEN
K. M.0, CASH SUPERVISING MECHANICAL ENGINEER
r t
Joel, z 4( ;' Aft
' r
6A°64Za eB APPLICATION FC RNI T,
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSXL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDINa
.JOHN A. LAMBIE, COUNTY ENGINEER
COLEMAN W. JENKINS, SUPT. OF BUILDING LOCALITY � � 91E'er t
NEAREST
--�
FOR APPLICANT TO FILL IN (ROSS 5T. - C/
LEGAL .I
DESCRIPTION LOT NO. OWNER '� $` 1 `t.
MA IL
BLOCK TRACT ADDRESS
NO, OF SLOGS. bf
SIZE OF LOT NOW ON LOT e 'er' CITY _ T TEL.. NO, 4.f_
USE OF
BUILDINGS -',"'. -} +�" J tf" 1P'plC.�� DISTRICTNO. 63•ROUP MAP ="FROG SED 9Y
BK PG s i
CONTRACT?,
ADDRESS 7 k - S4,l �w p.,rv-z),1-1 s a` CONNECTION DATA
IIT ` T "^
_ � - _ �E"��� TEL. NO. - - STATION DEPTH
STATE LIC MANHOIF_FEFERENCE UPPER
LICENSE NO: CLASS --LOWER
NO. �---- DESCRIPTION OF WORK FEE _ TYPE OF CONNECTION _-- LENGTH FROM _--u
1 HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L,TO P.L-
`PU BL.0 SEWER $5.DO --- — -
SEFTIC TANK.SEEPAGE P T OR P.C.NO
PITS.AND/OR DRAINFiELU $IO.00CO. P.NO. JOB NO.
.HOUSESEVJ ER CONNECTING TO -- IM—___--.
}} TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00 1CL
WON VECT_OUSE SEW BLDG OR AFFIDAVIT WASVFTi EgSE EIExY RECORD.iNSTR�Nt DATE P�
WORK TA.7 HOi SE SEWER $.3-00
OlERd'_OW StFPAIE PfT,DRA INFIELD
EXTN CESSPOOL,DRYWELL.MANHOLE $5.00 --- _--�- --�- ---- g
7 A't'T . _4RR-QR ABANDON HOUSE � _.� HWY.OR ST WIDENING
S*WCYi OR DISPOSAL SYSTEM � $3.00 �� � "'_- —'-
-- -- --- -- -------- -. STATE ENCROACHMENT Lu
I { PERMIT NO. fly
WASTE APPROVAL
OWNER'S PERMIT_ $
„ T `- CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE -- '; , E- --� _
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COM- REIMBURSEMENT FEE
'e TRACTOR TO,CONNECT THE ABOVE DESCRIBED EXISTING DWELLING _-,-
TO THE PUBLIC SEWER. APPROVALS DATE IPI.SPECTOR'S SIGNATURE
SIGNED THIS DAY�P __ tg_� ----- -------- ---...
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ ---- — CONNECT ADDITIONAL
ADDRESS
BUILDING.OR WORK
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ,AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS !EGULATING —
PLUMBING AND SEWERS it CESSPOOL. ❑ DRYWELL
I HEREBY CERTIFY THAT I AM 'OPE LY 'GI E ED AND/OR ALTER,REPAIR.SEWER OR LICENSED AS REQUIRE L CLE C T AD STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORN AOR THAT �,. AL N O NO INTEND T -� -`----- - -----
RESIDE IN,.THE AS ISE
RE DE IA R - ERTY. D SOONNEG7 PLUG AND - I
ABANDON HOUSE SEWER 1 _
SIGNATURE SE - -F-- _
OF PERMPTTEE( � 4 E'= CKFil L SEPTIC TANKS (�- ,�
SEEP.PIT(S) +O_CESSPOOLS
VALIDATION~. - - JACK LLEN
5UPERVISING MECHANICAL ENGINEER
!f CK. M.0. `CASH