HomeMy Public PortalAbout6051 ROSEMEAD BLVD_Sewer__ CE808 11-57 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Eng�s�e� _ADDRESS
CA'SSATT D. GRIFFIN, Supt of.Suildinq LOCALITY
6;
FOR APPLICANT TO FILL IN
NEAREST. s
LEGAL --
DESCRIPTION LOT N0. __ - _OWNER -
BLOCK TRACT MAIL -
_ _ADDRESS
N0.OF BLDGS..
SIZE OF LOT _ NOW ON LOT CITY TEL.N0.
USE OF _
BUILDINGS DISTRICT NO. GROUP MAT'
CONTRACTOR i BK PG
ADDRESS ;;.: CONNECTION DATA
CITY` /TEL.N0, i'- STATION DEPTH
STATE MANHOLE REFERENCE `7 UPPcR
REGISTRATION NO. -- 't;� '---' ,// Ej COUNTY LOWER—
NQ. DESCRIPTION OF'_WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CQNNEC7Y3NLENGTH FROM
PITS AND/OR DRAINFIELD @ $3,_00 _. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $2,00
HOUSE SEWER CONNECTING TO P.C.N0,
PRIVATE DISPOSAL SYSTEM @ $1,00 CO.IMP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR
WOR T_0_ToUSE SEWER @ $1,0.0 -�'- TRUNK PERMIT N0. ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @.$4.00 STATE ENCROACHMENT
PERMIT NO. -
INDUSTRIAL -
WASTE APPROVAL
CHARGES
OVVNER'SPERMIT S I 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FE_£—_� �� REIMBURSEMENT FEE
I HAVE AT THIS DATE ACONTRACT WITH THE HEREIN NAMED CON- -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE: (INSPECTOR-S SIGNATURE
TO THE PUBLIC SEWER, ---�--- ---
S[GNED THIS _ DAY OF--.—/ NEW HOUSE SEWER ---
OWNER OR - CONNECT ADDITIONAL
OWNERS AGENT �`� �� EULLDING OR WORK _
ADDRESS__.,`_ - x _ i_ ✓' �
SEPTIC'TANK,SEEP,PIT(S)
I.ND/OR DRAINFIELD____
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION _
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL[[I
WITH ALL COUNTY ORDINANCES. AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS, j
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL.SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY .AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM. THE LEGA. OWNER OF THE ABOVE- ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL,,PROPERTY BACKFILL SEPTIC TANKS 0
SIGNATURE / - - SEEP. PIT(S) IJ CESSPOOLS [:I
OF PERMITTEE
e VALIDATIC?I+] ROBERT A.IIII WOOD
CK, U.0. CASH SUPERVISING MECI,iANICAL ENGINEER
I 4 6,