HomeMy Public PortalAbout6216 ROSEMEAD BLVD_Sewer__ 7GA642b ,APPLICATION FOR PERMIT- 1
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Las Angeles aulLarNc , f ��
JOHN A. L.AMBlE, COUNTY ENGINEER --- — —.—�-_—.---.
CASSATT O. GRIFFIN, SUPT of 6u1Lb11`i:+ LOCALITY
NEAREST f'
-- _- _ FOR APPLICANT TOFILL IN -- - -- CROSS
_ -- ST_
TSRIPTION LOT O6LEGAL
DOWNEe,. _
09
BLOCK TRACT MAIL
--
ADDRESS r
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OF BLD Cr S �jL'R3C
_SIZE OF LOT f _;, CITY TEL. NOU -raowr F ILD USF.OKdUILDING5 ,.aaaDISTRICT NO. ! GROUP MAP
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CONTRACTOR ta .o-^ J' -ADDRESS _-- CONNECTION DATA�� sTArtoNz 5e� DEPTh
CITY __ .. TEL NO, --- MAPiHOLE REFERENCEREC153RATIO-N NO, ,.. ----` -- -1 —
ND j DFSC.RIPTI04 OF WORK FEE .._--
_. _— _-- — TYPE OF'
HOUSE ^
OUSk SEWER CONNECTING TO `a^, Y TiONB , PLENGTH FROM f 12
L. M.L.TO P.L. 'y
PUSa.tC 5 WFR @ $3.50
j _ ---- - --.— _-- -
- tP. - _.--- ----
SEPTIC TANK SEEPAGE PIT OR -
PIT$ANO OR DR.AINFIELD Q{ $.3.00! _ j -- - _--------.OVERFLOW SEEPAGE PIT,.URAIN LD --- —= 'F P G N0,
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Ext^F ESS POOL,DR1ELL RfANHOHOLE CRI 2.00 CO. IMP NO.
HOUSE'EWER CONNECTENG TO -- - I-- -
PRIVATE DISPOSAL SYSTEM co, ?1.00 ' TRUNK PERMIT N0,
ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG STATE ENCROACHMENT
OR j ^•-t
I ' `�'"�+ �• a� R
WOR HOUSE SEJdEP. (41 s 1.60 � � PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE i
SEWER OR DISPOSAL SYSTEM INDUSTR]AL
-. �._._ WASTEAFPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT �I -- —
0 REIMBURSEMENT FEE --
AUTHORIZATION TOTAL FEE
I. HAV .. THIS DATE A CONTRACT 'WITH THE 7HE tEREfN NA MED CON- -.._APPROVALS DATE I!NSPEGTORSS!G.NATURE
_
TF;-4CTC;H TO CONPiIu' THE ;,St?SE DESCRIBED F.;:I5TiNG DWELLING I i -
TC THE PUBLIC SEWER. -- - NEW HOUSE SENOR
g
SiG!NkD TE-IES 1' DAY 0 19_' y - - — ---
--e-- CONNECT ADDITIONAL
OWNER O �
. � ,'�`j� .l � UiI-DINC OR WORM
OWNERS —�----.--
OWNRS AGFNT 'Z -� SEPTIC TANK,SEEP,PIT ISI.. - --- -- _--
ADCREc 4.1 4", f' .v e.L t ,A�' af,. AND/OR DRAENFIELD
I HEREDY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[T DRS N'8LL[j
AND STATE 'FHE APOVE IS CORRECT A14D AGREL TO COMPLY"
WITH ALL COUNTY ORDINANCES ANID STATE LAWS REGULATING- ALTER,REPAIR,SEWER OR
PL,J. i d AND S -SRS. SEWAGE LISPO A OST E_M
I HEREBYCERTIFY THAT f AM PROPERLY REGISTERED AND/OR y 5CON(vEC7 PLUG AND
_
M p f.:AT I :ANI THE LEGAL OWNER OF THE ABOVE ABANDON HOU E SEWE-R
ICE: ED As C JIRED BY LOS ANGELES COUNTY AND TACE OF
CALl,C1R`Y?A OR �`
DESCRI ED PE.SiDENTIAL PROPERTY, HACK ILL SEPTIC TANKS E
SIGNATUREE
SEEP PIT(S) fWl CESSPOOLS�!
OF FERMi'rTEE
I I
IOH.N A.LAMWE, COUNTY ENGINEER VALIDATION ROBERT A. WOOL?, CHIEF PLEIG, INSPECTOR
0. CASH
SEP 19 4 e