HomeMy Public PortalAbout6243 ROSEMEAD BLVD_Sewer__ '6A 6.0 -CE808-10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIOL4A NG 7 J_
SSITY
FORAPPLICANT TO FILL INSTST. I
LEGALDESCRIPTION LOT NO. � r �� �•
n MAIL
BLOCK TRACT ADDRESS /L
J NO. OF BLDGS. '� ,n ') '7r� �,,._/ Jz�/
SIZE OF LOT y� NOW ON LOT CITY f+--'C TEL. NO. G / 9
USE OF
BUILDINGS C DISTRICT NO. GROUPBK PS MAP PROCESSED BY
CONTRACTOR L- '/ { (' ) l
2.
ADDRESS ,' c- ;jS -tel -.1` CONNECTIO DATA
CITY TEL. NO. f ,/ / STATION r� " rj'S •' DEPTH 2
STATE JJ l j✓ LIC t .� MANHOLE REFERENCE
ASS T P__: yr GRA
LICENSE NO; Ij ? F '-J CL
NO. I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM s
HOUSE SEWER CONNECTING TO CURB P.L. M.L.TO P.L.
PUBLIC SEWER $7.00 C'' P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR CO.IMP.NO. 3 JOB NO.
PITS AND/OR DRAINFIELD 510.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. d
PRIVATE DISPOSAL SYSTEM 83.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVCR [ASCMENI RECORD. INSTR.NO. DATE 0
WORK TO HOUSE SEWER 83.00
OVERFLOW SEEPAGE PIT,DRAINFIELD ix
O
EXTN.,CESSPOOL.DRYWELL, $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM $3_00 _ �V
STATEE ENCROACHMENT
MANHOLE $7.00 PERMIT NO. � ' !'' �" 44. 7 0-
INDUSTRIAL N
WASTE APPROVAL Z
CHARGES
OWNERS PERMIT s
AUTHORIZATION TOTAL FEE 6' I CONNECTION CHARGE FEE
1HAVE 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'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER 5' -
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
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
WIT HALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. 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 L AM THE LEBSAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND--
RES I DE
NDRESIDE IN. THE ABPV .CS CRIB RESIDENTIAL/PROPERTY. ABANDON HOUSE SEWER
SIGNATURE r�✓
OF PERMITTEE l BACKFILL SEPTIC TANKS ❑
' -- -- SEEP.PIT(S) CESSPOOLS ❑
VALIDATION CK. M.O. CASH
S b 0 tl 1 5.J �: >
6A 642D-CE808-10-71 APPLICATION FOR PERMIT,
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT QF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESS
ILDING
'/
CALITY
FOR APPLICANT TO FILL IN OsAREST
5T.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS. /'` �
SIZE OF LOT NOW ON LOT CITY -� TEL. NO. 2` •) S
USE OF DISTRICT NO. GROUP MAP ESSED BY
BUILDINGS
BK PS
CONTRACTOR / �{af'/- _- r .,,,�, ..Y ✓
ADDRESS / s // CONNECTION DATA
CITY / TEL. NO. f STATION��� �r../`y DEPTH
CLASS ` -�LIC
MANHOLE REFERENCE „'�•/'2L.6 LOWS
NO. -DESCRIPTIO OF WORK FEE 7a TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 $7,00 -
SEPTIC TANK.SEEPAGE PIT OR P.C.NO. '
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. ��v/, JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. a
PRIVATE DISPOSAL SYSTEM 0 $3.00 0
CONNECT ADDITIONAL BLDG.OR AYER I EASEMENT RECORD.INSTR.NO. DATE V
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD _
EXTN..CESSPOOL,DRYWELL, @ $_5.00 HWY.OR ST.WIDENING O
ALTER.REPAIR OR ABANDON HOUSE -+7. ~
SEWER OR DISPOSAL SYSTEM @ $3.00U STATE ENCROACHMENT v
-- W
MANHOLE 0 $7.00 PERMIT NO. C
INDUSTRIAL h
E APPROVAL
OWNER'S PERZ� tw S _,a CHARGES
AUTHORIZATION TOTAL FEEG' CONNECT. N CHARGE
10 �>
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEM T FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ✓C ��•�C-LL Com'
To THE PUBLIC SEWER. APPRO LS DATE NSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL _
ADbRESS
BUILDING OR WORK
_
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S) -
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYWEI I
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR..SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOS LSYSTEM
CALIFORNIA OR THAT I A HE LE L OWNER OF, AND INTEND TO DISCONNECT PL AND
RESIDE IN, THE. ABOV C /RESID TIAL PROPERTY. ABANDON HOUSEWER +'I
SIGNATURE Lj,>/; BAC KFILI SEPTIC TANKS ❑
OF PERMTTTEE A!' J
SEEP.PIT(S) ❑ CESSPOOLS /
VALIDATION CK. M.O. CASH
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