HomeMy Public PortalAbout6233 ROSEMEAD BLVD_Sewer__ IIDOF coumw ENGENEM SEWER—SEWAGE DISPOSAL. 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNW OF LOS "GEIM
WILLIAM J. FOX, COUNTY ENGINEER BUILDING °) 7
ADDRESS �? o��.1
FO APPU-CAbLT WPM L IN LOCALITY
BUILDING q 'NEAREST
ADDRESS ! CROSS ST.
LOCALITY • d DISTRICT NO. ReaW..for Inspection PERMIT NO. C
NEAREST vo' 6— i 's
CROSS ST. !
s• �,��_ R EI ED BY DATE I UED BY DATE
OWNER
MAIL w USE Z�Q/NE OCCUPANCY B MAP
ADDRESS ADDRESS •-_":. � �.r�- .7 J -...._� /T, I �. I /� V
CITY '7 r STEL. 0. dmot �"'��++ /o/
CONTRACTOR / �q� f
_ c CO.IMP.NO. z3'.m r
ADDRESS Q
JOB NO.
CITY �, - -qlELNO.
_ TRUNK PERMIT NO.
REGISTRATION NO. � ® COUNTY ROAD PERMIT NO.
DESCRIPTION LOT NO. / STATE ENCROACHMENT ,�ff +
PERMIT N0. �/)W y,,aCs � L 1 A el
BLOCK TRACT �} INDUSTRIAL
N0.OF BLDGS. WASTE APPROVAL
1 +F L�7,10
USE OF NOW ON LOT CHARGES
BUILDINGS C_ - / CONNECTION CH `RiBE FEE
NO. DESCRIPTION OF WORK FEE'
HOUSE SEWER CONNECTING TO -� REIMBURSEMENT FEE\
PUBLICSEWER E 9.50 RECEIPT NO. I ATE BY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR � i EX TIO RECORDED
WORK TO HOUSE SEWER 1.00
— ALTER OR REPAIR EXISTING - N I D I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
_ PITS AND/OjDRA NL FGEIT OR
R2.00 `�
CESSPOOL—DRYWELL STATION Vj DEPTH
SPECIAL CONDITIONS ONLY 2.00 i �.y� a MANHOLE REFERENCE
4OSLOWER
TYPEFO CONNECTION LENGTH FROM / D
OWNERS PERMIT $ I 00 ' CURB P.L. M.L.TO P.L. _
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING' APPROVALSINS CTOR'SSIGN DAT
DWELLING TO THE PUBLIC SEWE
SIGNED THIS7ZLD OF- NEW HOUSE SEWER °�•�• ' /','y
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT_.. BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(8)
ADDRESS..._......_:.__. _..�.�. ___._..__ _^._. AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR.SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED, DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
A D STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ��,,�,, ``
ER OF THE ABOVE DESCRIBED RES NTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)0 CESSPOOLS �G(2G[�L (�
l / 7p
al -S-16
OF PERMITTEE. -. � `?�'
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