HomeMy Public PortalAbout6247 ROSEMEAD BLVD_Sewer__ '6A 642D-CE808-10-71 APPLICATION FOR PiRMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Ft
_
FOR APPLICANT TO FILL IN
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF'BLDGS.
SIZE OF LOT Jt" NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS 01S TRICT N0. GROUP MAP ROCESSED BY
SK P5
CONTRACTOR a
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ADDRESS . "y:� ,;, ; -._--P CONNECTION DATA
1° STATION DEPTH J
TEL. NO.
CITU ',ee,a(�/X
STATE LICUPPER.,.y� .
LICENSE NO, CLASS MANHOLE REFERENCE
_n?/-. E.,t_ if,__' ._'y 1 -1.6WER
No. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P,L, M.L.TO P.L. ✓
PUBLIC SEWER $7.00
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR -- -
PITS.AND/
OR DRAINFIELD $10.00 CO.IMP.NO. JOB NO,
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 0.
PRIVATE DISPOSAL SYSTEM $3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAlv[R EASEMENT RECORD.INSTR.NO. DATE V
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD OL
EXTN..CESSPOOL.DRYWELL, $5.00 HWY.OR ST.WIDENING O
ALTER,REPAIR OR ABANDON HOUSE (-
SEWER OR DISPOSAL SYSTEM $3.00
iN STATE ENCROACHMENT Z �I VW
ANHOLE $7.00 PERMIT NO. 7;?C/
0-
INDUSTRIAL 0)
WASTE APPROVAL Z_
OWNERS PERMITS SOL% CHARGES
AUTHORIZATION TOTAL FEE 5 &"X CONNECTION CHARGE FEE
I HAVE 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 j - !
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 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 1 '
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM ww
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMTTTEE_T BACKFILL SEPTIC TANKS ❑
------'—'- - SEEP,PIT(S) ❑ .CESSPOOLS ❑
VALIDATION CK. M.0. CASH
2 4" f.:,.*+rt iO i tV
1 �
16A 642° - `E808-10-71 APPLICATION FOR PERMIT
wCOUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FCROSDSISST.
G
S
Y
FOR APPLICANT TO FILL IN .:- •:-
LEGAL - --- --
DESCRIPTION LOT NO, - OWNER
BLOCK TRACT '` �` '" ADDRESS
ry
VV, ..p.- NO. OF BGDGS.
SIZE OF LOT '1'+ C- X 3, --NOW ON LOT CITY
f (.
.f r..:,. :1 f, ♦ e., TEL NO. ,: .. �..
USE OF
BUILDINGS %�'." DISTRICT NO. GROUP MAP 70CESSE��•��D BY
BK PS
/ J , �Lys
CONTRACTOR s� CI � tl✓ ,(,•SGT...., �� �"`." _.i" +a.�i ,:, � / �v � �-'
ADDRESS . ..y, ,.,.. `� '... CONNECTION DATA
CITY
s. '.`
s , STATON DEPTH
.
STATELIC - MANHOLE REFERENCE UPPER
LICENSE NO, CLASS LOWER
NO. -DESCRIPTION OF WORK FEE7 E OP CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER Ct£ $7.00 `�� --�- ----_.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD $10.00
CO.IMP.NO. JOB NO,
HOUSE SEWER CONNECTING TOTRUNK PERMIT NO. ROAD PERMIT NO. `� d
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER -EASE...T RECORD.INSTR.NO. ATE 0
WORK TO HOUSE SEWER (@ $3,00
OVERFLOW SEEPAGE PIT.DRAINFIELD cz
E XTN.,CESSPOOL.DRYWELL, 0 $S.00 HWY.OR ST.WIDENING Y _
ALTER, HOUSE _ v
SEWER OR DtSP60*L SYSTEM $3.00 ` J� _ STATE ENCROACHMENT;;
MANHOLE PERMIT NO. ,/.,;.;� .i ,, �, -. uja
$7.00 --
INDUSTRIAL
WASTE APPROVAL z
OWNERSPERMIT CHARGES
AUTHORIZATIONI TOTAL FEE I
C CONNECTION CHARGE FEE
I HAVE 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
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
AN STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL 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
V '
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CAL FORN IA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED REST NTIAL PROPERTY.
_ ABANDON HOUSE SEWER
SIGNATURE * -�'� v✓ BACKFILL SEPTIC TANKS ElOF PER MffTEE ✓ -- SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION CK` M.0. CASH