HomeMy Public PortalAbout6043 ROSEMEAD BLVD_Sewer__ 5&5-S63f-SS� APPLICATION FOR PERMIT � 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
y s
County of Los Angeles BUILDINBUILDING a �
JOHN A. LAMBIE, COUNTY ENGINEER -ADDRESS.-
CASSATT D. GRIFFIN, SUPT of BUILDING � �
L O CAL i TY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST_LEGAL
_ .._ � � -
DESCRIP_TIQN LOT NO. ..� .� — _-OWNER
J -
MAIL
BLOCK _ TRACT - -- _ADDRESS_--� - — � t -
3 +C'_,
0,OF BLDGS, — `
SIZE OF LOT NOW.ON LOT '�.. CIT{ F"l f 'X ;t-
USE OF
BUILDINGS - DISTRICT NO: GROUP tAAP PG
CONTRACTORt�'£ '�,y= -P-e�r`"•'"_ .- - --- I -:r _ '''"�'..
COI3NECTIOTV DATA
ADDRESS
� � `` T"� ---- --- -._ --- --- -�---- --
f ,f '
_STATION
CITY i - TEL.NO.—,;�, HOLE RE
}ryANREFERENCE ,,✓ UPPER
---- 1. _ —�—_ _ .— --
C1 STATE. _ '�.4v � UPPER
REGISTRATION-NO. '� COUNTY Y ----
NC, DE CRIFTION OF WORK D
--- --- ------ ------ TYPE OF :�&KCTION LENGTH FROM
HOUSE SEWER CONNECTING TO I = y, CURB`: P.L. M.L.TO P,L, yam,
-' PUBLIC SEWER $3.50
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFI6 D r $3,00 - --- -- _ - -----
OVERFLOW SEEPAGE PIT,DRAINFiELD - P.C. NO,
' . 1
_....� EXTN ,CESSPOO LfA
_;DRYWFLL. ANHOLE 4 $2.00 C
- O. IMP N0OB N0.._... _..� .2 .
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM - Ct $1.00 I TRUNK PERMIT NO, ROAD PERMIT NO,
CONNECT ADDITIONAL BLDG,OR STATE ENCROACHIMENT
_I WORK TO HOUSE SEWER (it $1.00 �' ' ERMIT NO.
t
j ALTER,REPAIR OR ABANDON HOUSE - INDUSTRIAL
SEWER OR DISPOSAL SYSTEM _- rt $1.00 1 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S —PERMITS i DO
--- - REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREINNAMED CON. APPROVALS i. DATE: 'NNF£CTOR•S SiGNATURc
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC S£'i'iE` NEW HOUSE SEWER
SIGNED TNI .—DAY C77 - i9 �- CONNECT ADDITIONAL
OWNER OR - BUILDING OR WORK.---- _ -- _-S -_-.------ -
OWNERS AC - T.�- SEPTIC TANK,SEEP.PIT(5)
AND/0_R DRA1NFilLI-- - --------- --- ._.._ ._-..._
IJHEREBY AC Y{t OWLE00E' THAT-' HAVE READ 'PHIS APPLICATION CESSPOOLLI DRYWELLIj �
AND STATL THAI THE ABOV,jIt IS CORR-1;CT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANDIOR DISCONNECT PLUG AND
LICENSED AS
REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ----- - -- ----- --- ---- ---"----_
DESCRIBED RESIDENTIAL PROPERTY, - BACKFILL SEPTIC TANKS
SIGNATURE _ / ,,i` SEEP.PIT D CESSPOOLS Fj J
OF PERMITTEE --- ---
1OHN A. LAMBIE. COUNTY ENGINEER VALIDATIO ROBERT A.WOOD,CHIEF PLEG. INSPECTOR
sx. m.o. cAsyi
76A 6420 20.68. APPLICATION FOR PERMIT
Lf COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS, SUPT, OF BUILDING 1 d "
LOCALITY
NEAREST .,»+
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL /_
DESCRIPTION LOT NO. OWNER �/ +� .:-) A,.N
MAIL
BLOCK TRACT ADDRESS I
NO. OF BLDGS. .'
SIZE OF LOT_ _ NOW ON LOT CITY"� '-',�M`g ,�uCifli TEL NO.
USE OF
BUILDINGS DISTRICT NO, GROUP MAP PROCESSED BY
SK
CONTRACTOR /i, ONI C+ C. .tel.:,s,
ADDRESS ", ✓ '� ,`� J;%;%� �..ssy y,�'i'F CO ECTIDATA J
G ITY . TEL. NO. STATION DEPTH
STATE i
LIC 4. MANHOLE REFERENCE UPPER
LICENSE Np; '>_:213 "-)7 _ GL.A.SS Zj,' ,iT�i LOWER
NO. DESCRIPTION OF WORT( FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER -__@ $5.00 _ P.G.NO. -
SEPTICTANK-StEPAGE PfT OR I
PITS AND/OR DRAINFIELD @ SIO.00 CO.IMP. NO. JOB NO'.
j HEOUSSEWER CONNECTING T0' -� TRUNK PERMIT NO. ROAD PERMIT NO,
PRIVATE DISPOSAL 4YSTEM @ S3.00
CD
^jl-CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIY[II EASLMEMt RECORD. INSTR.NO. DATE C-)
ORK70 HpUSE EWER 53.00rlll
VERFLOW SEEPAGE PIT DRAINFIELD �__ CD
XTN.0ESSPOOL.ORYWELL.MANHOLE@ $5.00 ___LTER.REPAIR OR ABANDON HOUSE j- 1 HWY.OR ST.WIDENING w
SEWER OR DISPOSAL SYSTEM @ S3.00 _ �i STATE ENCROACHMENT
�...{ •^' ,/ PERMIT NO
J7
INDUSTRIAL
I WASTE APPROVAL
OWNERS PERMIT $ _iCHARGES
oo --- --- --
AUTHORIZATION TOTAL FEE -+—f.aCONNECTION CHARGE FEE - —
,
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO-CONNECT THE ABOVE DESCRIBED EXISTING DWELLING --- - ---- -----
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY +DF I9 — --- '—
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL _
ADDRESS. BUILDING OR WORK
.
1 HEREBY ACKNOWLEDGE THAT SEPTIC TANK,SEEP,PIT(S)
I HAVE READ THIS APPLITIbN. * AND/OR DRAINFIELD
AE:
AND STTTHAT THE ABpVI.' IS CORRECT AND AGREE TO Cb MPLY
WITH ALL COUNTY ORDINANCLS AND STATE LAWS RF_GULATING [IPLU MSI NG AND SEWERS. CESSPOOL ❑ DRYWELL
1 HEREBY CERTIFY THAT .I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA 04 THAT I A THE,LEGAL OWN'Etl?'F, ANLT'INTENO TO —'
f DISCONNECT PLUG AND
RESIDE IN, THE ABOt(aE ESC I@£O RESIDENT}'AL F�tPERTY ABANDON HOUSE SEWER
SIGNATURE iJJ �' '/�6.. _' ---- �-
OF PERMTT7€ , 1' - - ( `t i BACKILSEEP FP IT(STANKS
�P❑ CESSPOOLS ❑
VALIDATION-=-' ACK R. ALLEN
CK. M.0. t CASH I .S
SUPERVISING MECHANICAL ENGINEER