HomeMy Public PortalAbout5818 ROSEMEAD BLVD_Sewer__ 9D
a E-689 11-55
APPLICATION FOR PERMIT` - 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
.JOHN A. LAMBIE,COUNTY ENGINEER -ADDRESS
CASSATT D. GRIFFIN., SUPT OF BUILDING LOCALITY
FSSCR
FOR APPLICANT TO FILL IN
NEAREST•
OWNER
N LOT Fd Q. x,r -_
MAIL
TRACT ADDRESSN0. OF BLDGS. CiTY TF,L. N0.
NOW ON LOT DISTRICT N GRQUP MAP
PG
.. r
CONN_ECTION DATA
ADDRESS -' 'i ------
------- - ---- -- -- STATION F'. '� ..,T. DEPTH :
CITY - TEL. NO. - -"' -
---.--- -- - - - ---- - MANHOLE REFERENCE
'r
STATE -_ t�, ;d / • LOWE :'.
REGISTRATION NO. - C COUNTY -
NO. I DESCRIP'IION OF WORK FEE ---- - - - - -
--_._-_----_-.. -- TYPE CONNECTION LENGTH FROM
.' HOUSE SEWER CONNECTING TO .T CU A" •.� P-C- M.L.TO P.L. �f J
-J PUBLIC SEWER g $3.30 ---- ----
SEPTIC TANK SEEPAGE PIT OR
-j PITS AND/OR DRAINF+ELD --- a $3.00 i.--- _----- -�.—.------- .-�---
OVERFLOW SEEPAGE PIT, DRAINFIELU I C F 4 P C. NO..
FXTN ,CESS POOL,DRYS ELL,MAN HOLE r. $2.00 CO. IMP, NO S J6B'N0. R
HOUSE 5ENlER GONN£CT-IN G Tp $f.00 II: I STATE ENCROA-H�•M��£N � - -
PftiSA DISPOSAL SYSTEM I.00 -`---i----- PERMIT NO. N0- ROAD PERMIT NO 1!I
CONNECT ADDITI-ONAL BLDG OR-------.,--- --:.,__-._-`-------
WORK TO HOUSE SEWER c
t ALTER,REPAIR OR ABANDON HOUSE --NDU _ -- -- _---------�---
Sc EER OR DISPOSAL�Y=. _ _a:.,$1.00 INDUSTRIAL -
_�- _ -- _ _--- ( -- 'WASTE APPROVAL
CHARGES
------ ____._ CONNECTION CHARGE FEE
i UO
OWNER'S PERMIT T
5J .
------ � -- REIMB UPS:.M£NFEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A. CONTRACT WITH. THE HERE[PI NAME coN APPROVALS I DATE !INSPECTOR'S SIGNATURE
-TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PC.9LIC SEWER. NEW HOUSE SEWER
SIGNED THIS___._._.—DAY tih_, __ �_ 19CONNECT ADDITIONAL
OWNER OR _ BUILDING OR 4JORK I
OWNERS SEPTIC TANK,SEEP, PITS+--I .-
ADDRESS_- AICD/OR DRAINFIELD
REB A t THE ABOVE' A CORRECT READ
THISAGR'APPLICATION
CCSSPOnL I_}_CCiYW ELL-❑ _ �- -- ---- --- ^--_---
! hE�L6Y ACKNOWLEDGE THAT Fi A'dP
AND
----- -- ----------- ------
MPLY
WITH ALL COUN'T'Y ORDINANCES AND. STATE. LAWS REGULAT114G ALTER,REPAIR,SEWER OR �
PLUMBING AND SEWERS. SEWAGE DISPOSAL.SYSTEM
-
I HEREY C[*RTIFY THAT I AM PROPERLY REGISTERED _ ._ ----
AND/
OR DISCO NNECT PLUG ANDL.I
LICENSED AS REQUIRED 5Y LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT i AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS III
SEEP. PIT(5) 'Ll CESSPOOLS El '
SIGNATURE _ ._._- ------------
SJFPERM ITTEE
1
JOHN A. LAMBIE,COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF fPLBG. INSPECTOR
LASH
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