HomeMy Public PortalAbout6240-6242 ROSEMEAD BLVD_Sewer__ 7 as�a� APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY S EW E R-SE WAGE DRI
Department of County Engineer
County of Los Angeles BUILDING f
WM.J. FOX, COUNTY ENGINEER _ADDRESS
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY
-TEL
FOR APPLIC1iNT 'TCB F14L IN
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LEGAL j � . ..�.__.._—
DESCRIPTION LOT NO. jf*- GWNER
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B`¢
Bt,ocK��.-..l��"� �AeT a�3 R_�g �tntL
�tlio.OF BLDGS. ._----
SIZE OF LOT_ - _.^ - NOW ON LOT_ CITY � CEL. N0,
USE OF --
BUILDIPaGS DISTRICT NO. GROUP f MAP
PG
CONTRACTOR
ADDRESS I CONNECTION DATA
CITY �_-,- - �iEL. NO. _STATION °7 '- -.�,7 DEPTH .f
L STATE MANHOLE REFERENCE
REGISTRATION NO. - ('_l COUNTY �� _UPPER .. �
TYPE OF 5NW CTSON LENGTH FROM
No. DESCRIPTION OF WORK FEE r� _ R8 1 P.L, M.L.TO P,L. °
HOUSE 'SEWER CONNECTING TO
.��..,.I
PUBLIC SEtii'ERh 5 3.50
HOUSE SEWER CONNECTING TO
PRiVATE DISPOSAL SYSTEM _ t.00
CONNECT FDD(T1ONAL BV_0G, OR i
I WORK TO HOUSESEWER f:GO_i. . CO. IMP. NO.� �-� JOB_N0_ —
�+! ALTER OR.REPAIR EXISTING _- (� J
SEINER OR DISPOSAL SYSTEM 1.60 1 I TRUNK PERMIT NO. ROAD PERMIT N.O.
Dt S CONNECT AP L� S NDO a SEWER
STATE ENCROACHMENT
_
AND/OR DISPOSAL SYSTEM 5.00 ��- ( PERM;l"NO.
SEPTIC SANK, SEEPAGE PIT OR � _-- 'i� .
PITS AND/OR DR.AINFIELD 2.00 `.N - S.rR.AL
�---_i CESS�O.,L Di"4'bl'ELL- I WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
O Iw PER3b2iT +- ! 00 - `co:eNEGT1oN CHARGE FEE —
AUTHORIZATION T®IAL FEE EIMBI RSEI�ENr�EE
f '
IAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRH p APPROVALS
ACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING Dt'JELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER — -------"---- -
NEW HOUSE SEWER
SIGNED THIS. DAY OF---1 9--
-OWNER OR CONNECT ADDiTIONAL _
OWNERS AGENT _BUIL_D_ING_OR WOP.K
SEPTIC TANK.SEEP, PITS) -
ADL'RESS_- - _SNDOR DRAiNFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL L DRYW£LL 0
AND STATE THAT THE AEOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING .AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/-OR DISCONNECT PLUG AND —
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE. ABOVE __ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY, BACKFILL SEPTIC TANKS CI
- 3 _SEEP.PIT(S).Q CESSPOOLS
SIGNATURE 'af �'..
OF PERMITTEE e
WILLIAM J.FOX,COUNTY ENGINEER VALIDATION
50331-� JAN7 a 4.5r m
BY BY
DEPUTY ( 4 DEPUTY
BY BY
DEPUTY DEPUTY
76A642D 64 APPLICATION FOR PERMIT'
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING +j r'
JOHN A. LAMBI£, County EngiaeexADDREss ( e
WILLIAM A. JENSEN, Sup't of Building T�
LOCALITY SO,t
FOR APPLICANT TO FILL IN
- cRDss sT -
- - ------ -- - - -
DE_SCRIPTION LOT NO _ �,� _ .I f � ✓��
_
MAIL
i. BLOCK TRACT ,l -f L�_ ACDRESS
—� NO. OF SLOGS,
SIZE OF LOT NOW ON LOT CITY TEL. NO.
BUELDINGS DISTRICT NO. GROUP MAP PROC ESSF�+BY
�.,
BK
j
CONTRACTOR . '
ADDRESS ` q '' CONNECTION DATA
- ! ass r� STATION -.
� � . DEPTH
CITY .y,� .� - ^ TEL. NO,� � `"" _ � � _
STATE MANHOLE REFERENCE l
P PER
REGISTRATION NO. a `4,t ,� .LJ`' COUNTY r
NO. DESCRIPTION F WORK FEE_ TYPE OF CONNECTION LENGTH FOM / _—
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P,L; d _
PUBLIC SEWER moo �
SEPTIC TANK.,SEEPAGE PIT OR P.C.NO. a"
PITS AND/OR_DRAINFIELD $10.00 CO,IMP.NO. JOB NO. i6.
HOUSE SEWER CONNECTING TO I TRUNK PERMIT NO. ROAD PERMIT NO. 0
PRIVATE DISPOSAL SYSTEM $3,00
J CONNECT ADDITIONAL BCOG.OR AFFIDAVIT wgveE EesEMENT RECORD.INSTR.NO. DATE Ind
O
WORK TO HOUSE SEWER 0 $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELDt—
EXTN„CESSPOOL,DRYWELL,MANHOLE* $5.00 V
AL'I'E,'R:-REF��TR ABANDON HOUSE _ HWY,OR ST.WIDENING a.
SEWER OVFC'II78`R65}X L SYSTEM $3.00 ` STATE ENCROACHMENT -� In
.- �. - PERMIT NO. Z_
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 1100
GHARG es
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I `
`IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -
TO THE PUBLIC SEWER, APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ `
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS._, BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEW ERS, CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A�CVE DESCRIBEO RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
(J°r�' F..... [
SIGNATURE
PERMITTEE r '`"3'm.3 --•,.a> * '` BACKFILL SEPTIC TANKS ❑
SEEP.PIT(5) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK, M.O. CAS
SUPERVISING MECHANICAL ENGINEER
H ,+
5469Z8 OCT 251 U p 5.00-
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