HomeMy Public PortalAbout5943 ROSEMEAD BLVD_Sewer__ 76Ai%1.LD
CE 808(REV,6I78i APPLICATION FOR PERMIT
Cis
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT N. GROUP MAP ROCE ED BY
Pyr �.
UILDING C_.' .�'. �
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ADDRESS L.
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CONNECTION DATA'
LOCALITY
NEAREST STATION "' DEPTH
CROSS ST. _,,,...�G.---wry - C� ''.
MANHOLE REFERENCE/
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OWNER - ^`• TYPE OF ON LENGTH FROM/
MAIL Y. CURB =' P.L. M.L.TO P.L.
ADDRESS --;}'
P.C.NO.
CO.IMP.NO. 7 �'.� JOB NO.
CITU TEL.NO.'`"" _`]`
LEGAL ✓ / TRUNK PERMIT NO, ROAD PERMIT NO.
DESCRIPTION LOTNO.,–J—e f k-/
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT;, ,y.
NO.OF BLDGS.
SIZE OF LOT NOW ON.LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS - STATE ENCROACHMENT `y..
PERMIT NO.
CONTRALTO INDUSTRIAL ''
.ems WASTE APPRORAI, __' �,! f:.,.:g
ADDRES / CHARGES
CITU ( TEL CONNECTION CHARGE FEE
.NO. f
STATE s 1 t. - LIC. REIMBURSEMENT FEE
LICENSE NO. CLASS - 0
NO. DESCRI TION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE u
HOUSE SEWER CONNECTING TO g IN
y PUBLIC SEWER r�Yp O
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG,OR SEPTIC TANK,SEEP,PI7151
WORK TO HOUSE SEWER AND/OR DRAINFIELD
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL El DRYWELL❑
EXTN.,CESSPOOL,DRYWELL.MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑ r �'
SEEP,PITI51_a CESSPOOLS❑
OWNER'S Permit s VALIDATION
AUTHORIZATION I TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- F ,
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGN T IS DAY OF. 19_
OWN
OW Af JE'
S
1 H, REBY ACKNOWLEDGE AT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOV 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AN SEWERS.
I HEREggtt��//'�ANP
THAT I AM PROPERLY REGISTERED AND/OR
LICENSED.AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFOR A OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO RE-
SIDE IN. E ABOVE DESCRIBED RESIDENTIAL PROPERTY.
S(GNAT E _v^y4