HomeMy Public PortalAbout5910 ROSEMEAD BLVD_Sewer__ 76A 6420 —CE808-10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING `
ADDRESS
LOCALITY -�
NEAREST
FOR APPLICANT TO FILL IN CROs ST.
LEGAL
DESCRIPTION LOT NO, OWNER
. -- MAIL ,? Yi ,.
BLOCK TRACT ADDRESS If r
O
SIZE OF LOT NOW ON LOTS CITY 't 1 TEL. NO.
USE OF
BUILDINGS .DISTRICTNOGROUP MAP PROCESSED BY
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CONTRACTOR �. fV J 'a f' .�.Z. ° I -
ADDRESS P' qs�JJ r I CONNECTION DATA
CITY TEL. NO. / L/Y �a`"TI STATION -- DEPTH
STATE , y^ LIC ^� MANHOLE REFERENCE UPPER
LICENSE NO. �a.;.' J t"�p CLASS
�. ✓ LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P,L. M.L.TO P.L.
PUBLIC SEWER 0 $7.00 P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR JOB NO.
PITS AND/ORDRAINFIELD 310.00 CO.IMP.NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 0-
CONNECT ADDITIONAL BLDG.OR AFRI DAVIT T WAIVER EASENENT RECORD.INSTR. NO. DATE
WORK TO HOUSE SEWER 0 33.00
�^ OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL,DRYWELL, $5.00 HWY.OR ST.WIDENING O
R hE'f7V,REPAIR OR AIM"VIDN HOUSE __ I�
I SEWER OR-D*r'P49ftt SYSTEM $3.00 STATE EN CROACH HENT V
_ W
MANHOLE $7.00 PERMIT NO. p„
---- INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 3 00 ---
AUTHORIZATION I TOTAL FEE y CONNECTION CHARGE FEE —
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT EIMBURSMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
70 THE PUBLIC SEWER. APPROVALS DATE I NSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS - SEPTIC TANK,SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT I 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 REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
i HEREBY CERTIFY THAT I AM']PROPERLY REGISTERED AND/OR iw67ci7,REPAIR,SEWER 0+1-
LICENSED AS RE0jl;I �M
Y L ..ANGLES COUNTY AND STATE OF S5�'A-tSf-DQBA_7t::S:L`SELi
-
CALIFORNiA OR TH ,7' EGALOWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A5 EDREIDENTiALPROPERTY.15 ABANDON HOUSE SEWER
SIGNATURE (,,/,9 y
OF PERMITTEE_ �1�� f BACKFILLIT SEPTIC TANKS ❑
— ---' SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION CK. M.O. CASH
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