HomeMy Public PortalAbout5919 ROSEMEAD BLVD_Sewer__ 76A 64ZD-CES08 A-7/76 APPLICATION FOR PERMIT
SEWER—SEWAGE DISPOSAL u
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
DISTRICTNO. GROUP MAP
FOR APPLICANT TO FILL IN BK PS PROCESSED BY
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ADDRESS c ` aL, ) ,
LOCALITY
CONNECTION DATA
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P.C.NO.
CITY -TEL. NO, 3'
C, CO.I.P.No. ed1 JOB NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LCT NO.
AFFIDAVIT I wAIYER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS
STATE ENCROACHMENT
- -- PERMIT NO.
/ INDUSTRIAL
CONTRACTOR - �. >'+.' G� WASTE APPROVAL
ADDRESS G i s, 3 IIV• Iyl U`<_�A*re-L- CHARGES
5
' CONNECTION CHARGE FEE
CITY � _j` L,TEL. NO.
STATE LIC (j��`� REIMBURSEMENT FEE 0
LICENSE NO. 3 j. CLASS K/'
No, I DESCRIPTION OF WORK FEE APPROVALS DATE INSPECT R'S SIGNATURE L,I
HOUSE SEWER CONNECTING TO N
PUBLIC SEWER
SEPTIC TANK.SEEPAGE PIT OR NEW MOUSE SEWER Z
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM @ SEPTIC TANK,SEEP,PIT($)
CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT.DRAINFIELDINAMEDCON-
ESSPOOL ❑ DR-YWELL ❑
EXTN..CESSPOOL.D RYW£LL,MANHOLEALTER,REPAIR,SEWER OR
ALTER,REPAIR OR ABANDON HOUSESEWAGE DISPOSAL SYSTEM i
SEWER OR DISPOSAL SYSTEM _ I
ISCONNECT PLUG AND
BANDON HOUSE SEW ER
ACKFILL SEPTI_T TAN ❑
EEP.PIT f51 ❑ CESSPOOLSIC3
OWNER`S Issuance Fee AUTHORIZATION TOTAL FEE I HEREBY ACKNOWLEDGE THAT I HAVEREAD THIS APPLICATION
NDSTATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
ITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
I HAVE AT THIS DATE A CONTRACT WITH THE HERLUMBING AND SEWERS.
TRACTOR TOCONNECT THE ABOVE DESCRIBED EXI1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SEWER. LICENSED AS REQUIRED BY LOS ANGLES COUNTY AN SSIGNED THIS DAY OCALIFORNIA OR THAT 1 AM TH 'LEGAL OWNE{jpF, A)( INTEND TO
OWNER OR ESIDE IN, THE. ABOVE DE5C ED RESIDEN IAIL ERTY,
OWNERS AGENT IGNATURE
OF PERMTTT .-'�+'�"�"""•-
ATIO
CK, M, CASH
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