HomeMy Public PortalAbout5942 ROSEMEAD BLVD_Sewer__ DEPARTIIrUNT OF COUNTY ENGL*TEE$ SEWER-SEWAGE DISPOSAL- 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES _
UILDIN
WILLIAM J. FOX, COUNTY ENGINEERIQ
ADDRESS
LOCALITY.
�F -A.-APPLICANT
FILI. IN , �'
ADDRESS.�,J' / `.r). r" NEAREST �{� eS
!� rte__ 'CROSS ST. P r �' d`
LOCALITY DISTRICT SERIAL N0. �PER N�
NEAREST _ _A /`� 7
CROSS ST. � �' ��-'.� RECEIVED,:BB Ready for Inspection DATE ISSSU
OWNER ✓Y.+ Gv'/ ..` rte/
ADDRESS USE Z0W." OCCUPANCY BK MAP PG
CITY TEL.NO. I y
v
CONTRALTO ,!/ : , ;1�� CO.IMP.N0. .
ADDRESSF '� f
..�� �.- �`' JOB.N0. -
CITY '� ,r, NO Atev TRUNK PERMIT NO. -
V` F"" ,,. v r-�8'f"-ATE •
REGISTRATION N0. �.��j ®.COUNTY ROAD PERMIT N0.
LEGALSTATE ENCROACHMENT-..
DESCRIPTION LO i PERMIT NO. ,o-�SG�►i//!,s
BLOCK TRACT - INDUSTRIAL
WASTE APPROVAL
812E OF LOT . ..� J NO-OF BLDG& CHARG
J NOW ON LOT
USE
BUILDINGS �+ CONNECTION CHARG EE
l
NO. DESCRIPTION OF WORK .FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
'PUBLIC SEWER G $ 3.00 RECEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR. _ XCEPTI N RECORDED
WORK TO HOUSE SEWER 1.00 N .
ALTER OR REPAIR EXISTING - I ATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 _ CONNECTION DATA.
SEPTIC TANK,SEEPAGE PIT OR •��� 0JR
-PITS AND/OR DRAINFIELD 2.00 `STATION ® DEPTH -
CESSPOO L—D RYW ELL
SPECIAL CONDITIONS ONLY 2.00 -� I , MANHOLE REFERENCE
G / LOWER
TYPE OF TION - LENGTH FROM
OWNERS PERMIT $ I 00 M.L.TO P.L. ,
r
AUTHORIZATION TOTAL FEE u��
I HAVE THIS DATE CONTRACTED WITH THEHERE& NAMED t
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING. APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS.—" DAY OF____19_, NEW HOUSE SEWER ,oA rilGk
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT_._._.._.. ._.._._.._.._ BUILDING.OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS........... ._.:...—..__—._..._._.—..—._:.—_..—._.....--..___. AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- . CESSPOOL 0 DRYWELL 0
CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL-COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED-
AND
EGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND
DISCONNECT ABANDON HOUSE-SEWER PLUG PLUGAND
AND STATE OF CALIFORNI OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DESC BED RESIDENTS L PROPERTY.- BACKFILL SEPTIC TANKS _
,,SEEP.PIT(8)o CESSPOOLS
SIGNATURE
OF PERMIT&E
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