HomeMy Public PortalAbout6038 ROSEMEAD BLVD_Sewer__ 6A642D52 APPLICATION FOR PERMIT � u
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
CEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F3uILpING €
" JOHN A. LAM$IE, COUNTY ENGINEER ADDRESS -
COLEMAN W. JENKINS. SUPT OF BUILDING �
LOCALITY y
NEAREST .,y
FOR APPLICANT TO FILL IN CROSS_ST = ; - C Z"
LEGAL �q
DESCRIPTION_ LOT NO
-— _ -if-`i- MAIL
BLOCK .... TRACT ADDRESS 41
SIZE OF LOT J (/. y'VI NOW ON LOT -__ G _ CITY f �t m.m . .tip.' TEL. NO.
USE O'
aUILCtI N S �Y_ - d p:STRiCT NO. GROUP MAP OC ESS ED BY
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CONTRACTOR 3_ - �+ �u`✓ `� Y;. ,� .
ADDRESS --/ - � i CONNECTION DATA >-
CSIt-- _�0,.
.
STATION r -T— DEPTH
TY ce ,
- 1PPERTATLIC
L!CEN E LASS �ERENCE /1 17 0
NO, �WORK '
_
_ FEE TYPE OF CON CTItlN c� 9 � NGTH FROM 9'
j HOUSE SEWER CONNECTING TO *,,,, Y. `URB P,L_ M.L.TO P.L_
JI;
I PUBLICSEWER G' $5.00
P.C.NO.
SEPTIC TANK SEEPAGE PIT OR � !a
PITS AND OR DRAINFIELD @ $14:00 CO.IMP. NO, JOB NO.
-.____
HOUSE SEWER SAL NECTTO TRUNK PERMIT NO. ROAD PERMIT NO,
PRIVATE DISPOSAL SYSTEM
E'M C $3.00
CONNECT ADDITIONAL BLDG OR T- '' AFFIDAVIT WAIYER EASEMENT RECORD.3NSTR.NO-� DATE
WORK T4 HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT pRAINFiELD
EXTN.,CESSPOOL.DRYWELL.MANHOLE @ $5.00 - ----- -- _—� --- ---
-- -- ---I - HWY.OR ST WIDENING
ALTER,REPAIR OR ABANDON HOUSE !
_ 5EWER OR DISPOSAL SYSTEM C $3.00. STATE ENCROACHMENT r
PERMIT NO
- ------- -- i -- INDUSTRIAL
WASTE APPROVAL
.�.__..__-_ -- `—.— CHARGES
OWNER'S PERMITs i 2i oo -- --- -
T-- CONNECTION CHARGE FEE
AUTHORIZATION TOTAL. FEE =!�r j xr0�} - — --`
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
7R AC70RTO CONty EC'1 THE ABOVE DESCRIBED EXISTING DWELLING --- - --
TO THE PUBLIC SEWER ,.+,. APPROVALS DATE INS P TOR'S IG NATURE
SIGNED THIS DAYI 19
OWNER
- t�- --
OWNER OR ;f' ' � NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
j` str SEPTIC TANK,SEEP,PIT(S)
I HEREB AC- K OW EDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15. CORRECT AND AGREE TO COMPLY -.— --
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEW ERS. CESSPOOL ❑ DRYWELL
I HEREBY CERTIFY THAT IU
PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COLI NTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDElNTIAL PROPERTY. ABANDON HOUSE SEWER '
SIGNATURE +l ¢ - BACKFILL SEPTIC TANKS Cl �p �^"'9
OF PERM.TTTEE, P 'r - SEEP,PIT 15) ❑ CESSPOOL
VALIDATION ACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CASH
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