HomeMy Public PortalAbout5932 ROSEMEAD BLVD_Sewer__ �E848 14-68
6A642r APPLICATION FOR PERMITe
COUNTY OF LOS ANGELES SEWER—SEWAGE AISP�JSL
DEPARTMENT OF COUNTY' ENGINEER
BUILDING AND SAFETY DIVISION FOC
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JOHN A. LAMBI£, County Engineer ��.,L..�'XtY _ _ A� c'.
WILLIAM A. JENSEN, Sup" of Building �yy �#s�e� (y���. I d t
FOR APPLICANT TO FILL IN cROSST.
f ES::R F TIVN ->T NO. k42'_.4 OY-PIER _ � ) �._
a. MAIL `
BLOCK TRACT u.-
.y,J ADD RES'
v. ,r NO. OF 11LDGS.
SIZE J I_OT�#, pry f'�p �, NOW ON I Ot'
- ° '_�-"_-f-"'--- _ SO"' CITY - .. �. TE:_. NO.
USE OF -.._.-.___-__-._._.--_-
13UILDINGS D!5TRiCT N GROUP MAP PROCESSED BY
BK
PG
CONTRACTOR
-- - - - — -
ADDRESS CONNECTION DATA
STATION DEPTH
CITY T'[;,L. NO:
n STATE: MANHOLE REFERENCE: UPPFR
REGISTRATION. NO. COUNTY _OWER
N0. GFSCRIPTICtJ OP WORK FEETYPE
OF
_—.-__ -_-__.___
7YPEOF CCN NEC'PfON LENGTH FROM
HOUSE SEW£R COPlN Ec:?ANG TD I Y. CURB P.L. M L..TO P.L. �^
PUBLIC SEWER $5.00 ---
P('. NO.
<, . rF.l
P IC 7's.NK SEEPAGE PIT OR
CO
O. IMP NO. JOB NO. .'
P TS AND/OR DRAiNF;ELD $14.00
HOUSE 4E4V R CONNECTING TO r TRUNK PERMIT N-O. ROAD PERMIT NO.
WUR KETO HO S'=SEWER $3.00
GR- s3.04. � _ .__-_.. T._-_,---.NO,
_. I_._.-
-^ C APPIRAVIT w'AIV_a I. Y0.;.E MENT REC OfiD. INSTR.NO. DATE I--
�OV F',R FLCIJ SEE PRGE
PIT,DRAINPIELG
EXT'N CES FOOL DRYW�'E L.MANHOLE @ $5.00
yy _- _T __ -�.- HWv OR ST WIDENING
AL CH REPAIR OS ABANDON HOUSE ? ._- _.__ -_
-.t EN fg OR DISPOSAL SYSTEM $3.04 '' - —'- -- _ F-..
-- STA EENCRC?.AC!-YM£NT ,f -fir
I,� y PERMIT N
INDUSTRIAL
I' WASTE APPROVAL
J CHARGES
OWNRR PERMI_T . 2 a0
AUTHORIZATION TOTAL FEE CONNECTION CHAS E FEE
' a " - - — --- --- ----- ------— —
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REiME3U RS__M°pE:PJ=FEL:
DA
TRACTOR. `"O r"NNEC7 THE ABOVE DESCRIBED EX[S1"iNG bW ELL
ING APPROVALS ..-
70 THE PUBLIC- SEWER. T£ iNSPECTpR6 SIGNATURE
SIGNED THIS —DAY OF_ 19_ ----- —... - - -----'--_ ..— _
OWNER OR NEW HOUSE SEWER
OWNERS R -_._. _.-..- i'-- -:� --- ..-- --
--`. '-- ------ CONNF'.CT ALDITIUNAL I
BU I DING OR WORK
ADDRES
-" - SEPTIC ANA. FIEL PIT49$
I kF_PWSY ACKNOWLEDGE TI..A7 I HAVE, READ T}'75 APPLICATION ,AN Di'OR DRA!N£'IEL_D
AND SKATE. THAT THE ABOVE IS CORRECT AND AGREE T'O COMPLY
WITH ALL COI;NTY ORDINANCES AND STATE LAWS REGULATING -____—__.____-_-
pi_
CIM BIND AND SEF4`ERS. CESSPOOL, ❑ DRYWELL ❑
H F_REBY 'CERTIFY THAT I AM PROPERLY REGISTERED ANC/OR ALTER,REPAIR,SEWER OR
CENS£C AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE:DISPOSAL SYSTEM
:—
CAL160RN1A 4?R THAT 1 AM THE !_£GXL. OWNER OF, AND INTEND TO DISCONNECT PLUG AND -
RE5!D SN., THE ABO`dE DESCRIBED ftESI.DENTI Ai.. PktUFE RTY. ABANDON HOUSE SEWER
SIGNATURE
❑ —
OF PERMITTEE-__. / BACKFILL SEPTIC TANKS ,❑ ( 1
_._ - _ BEER,PIT(,—) la CESSPUULS �
.. .-,-",VALIDATION
ROBERr A. Wooa
I
SUPERVISING MECHANICAL ENGINEER
CK,/ M.O. CASH
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