HomeMy Public PortalAbout6236 ROSEMEAD BLVD_Sewer__ CE808 ''70
76.A 642[) APPLICATION FOR PERMIT IV,
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE. COUNTY ENGINEER
COLEMAN W. JENKINS, SUP-T. OF BUILDING LOCALITY
ADDRESS
LOCA
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FOR APPLICANT TO FILL IN CROSS ST.
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F.E55CRIPTION LOT N J1.
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BLOCK TRACT 11 MAIL
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NO. OFBLDGS.
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BUILDINGS '/_vC LA Sl 0 X PROCESSED 3Y
DISTRICTNO. G 'AAP
CONTRACTOR
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ADDRESS
CONNECTION DATA
CITY TEL. NO. STATION
DEPTH
57ATE: LIC -- - -�- UPPER
LICENSE NO; CLA SS 1-y MANHOLE REFERENCE
---TYPE OF CONNECTION LENGTH F
DESCRIPTION OF WORK FEE
HOUSE SEWER Y
URS P.L. M.L.To P.
,N�-PUBLfC SEWER -&3.00- 21 —
7 --E- P.C.NO.
SEPTIC FAVK.SEEPAGE OR -t-
AND/OR DRAINF!ELD 0 CO.IMP. NO. JOB NO.
HOU-SE SEWERCOMWE&T-1 CONNECTING TO— TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM 53.00
CONNECT ADDI7!ONAL BLDG OR - AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER 53.00
OVERF-LOWSEEPA-Gir-PrE.DRA.-"NFIEL115-
____EXTN,.CESSPOOL,DRYWELL.MANHOLE 0 S5.00 124
ALTER,FEPAIR OR ABANDON HOUSE
HWY. OR ST.WIDENING 0
_�!�;WER OR DISPOSAL SYSTEM $3.00 6T-AT-E-E--N-CR-OA-C-H-.M-EN-T-- u
PERMIT NO. Lu
INDUSTRIAL
WASTE APPROVAL
CHARGES
}}OWNERS PERMIT_ 00
CONNECTION CHARGE.FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON, REIMBURSEMENT FEE
T RACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
H Y-
TO THE PUBLIC SEWEJR J " DATE INSPECTOR'S 519NATPRE
SIGNED THIS A,,�PAY-01— 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT.
CONNECT ADDITIONAL
e-y BUIL.DING OR WORK
AOORFSS-
p
C.TANK,SEEP,PIT(5)
7?�IKN.V�VLEGE T� FE
STATE THA
I HE
AND T THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/ORDRAFNFiELO
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
MB SEWERS.
PLUMBING AND S RS. CESSPOOL DRYWELL
IE)HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSEAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO
D,SCONNECT PLUG AND
RESIDE IN, THE ABOV-
R BED RE:/51DE PROPERTY.
ABANDON HOUSE
SIGNATURE
OF FERMrTTE BACKFILL SEPTIC TANKS
7
SEEP.PIT I s) El CESSPOOLS
VALMATION- JACK R. ALLEN
4 SUPERVISING MECHANICAL ENGINEER
CK.
M
O. i� CASH
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