HomeMy Public PortalAbout6202 ROSEMEAD BLVD_Sewer__ oil
% '",/
6A 642D -- CE808 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /f�
ADDRESS 'f L+' 'A
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN GRD55 57.
LEGAL �y —
bESCRIPTION LOT N0,4„yr�.✓ ,Ll"t,e kraY,,,� — OWNER
/ MAIL
BLOCK TRACT r 0 t, ADDRESS J
NO, OfF 13L _2
SIZE OF LOT NOW ON LOT CITY TEL. NO. 7
USE OF ^�
BUILDINGS fD . DROOP MAP �PROCED BY
l SK PS
CONTRACTOR JADDRESS CONNECTIONDATA�_r_ i ') p y y C DEPTHC17Y TEL. NO. �y jf STATE LCLICENSE NO; (J. ' p'% CLASS F NCErNO.. DESCRIPTI NV Of W R TION LENGTH FROOM
HOUSE SEWER CONNECTING TO '�6.�? CUR- P.L. M.L-TO P.L.
PUBLIC SEWER �. ._,SEPTIC SANK.SEEPAGE PIT OR �,.• P.C.NO"PITS AND/OR DRAINFIELD . J08 NO.
HODS£SEWER CONNECTING TO _3� TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ 6;.
[--T-- ---IIIK
NECT ADDITIONAL BLDG.OR �` '} - AFFIDAVIT WAIVER I EAStMENT RECORD"INSTR,NO. DATE
70 HOUSE SEWER.
RFLOW SEEPAGE PIT,DRAINFIELD _
N..CESSPOOL.DRYWELL..
ALTER,REPAIR OR ABANDON HOUSE
M ��q'__ j
HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM :f3CD0, CD
-. �— STATE ENCROACHMENT {/""
MANHOLE PERMIT NO. '� " '�` .,,, Q
a/
-- — INDUSTRIAL rI y
WASTE APPROVAL DO
CHARGES �
OWNER'R PERMIT------"— s oo
AUTHORIZATION TOTAL FEE rx CONNECTION CHARGE FEE -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC_ SEWER. DATE INSPECTOR'SSIGNATURE
SIGNED THIS DAY OF 99—
OWNER OR NEW HOUSE SEWER
OWNERS AGENT— CONNECT ADDITIONAL
ADDRESSBUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE: THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ---
WITH ALL COUNTY <RDINANC£S AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ElDRYWFLL [II HEREBY CERTIFY TH # AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED "P LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIr"RNIA OR THAT I-';AM THE LEG L OWNEP,, F. AND INTEND TO - DISCONNECT PLUG AND
RESfDE IN. i A _ Y UES GRI B RE 'bE ,.1'A L"PROPER - ABANDON HOUSE SEWER
SIGNATU
OF PE4iM TEE `p' ,d`�•� B CKFILi.5EPT T.AN ❑ �:.,•--
' 7{� SEEP.PIT(S) CESS OLS a
VAMMMA ON CK.
KM.O. CASH