HomeMy Public PortalAbout6270 ROSEMEAD BLVD_Sewer__ CE6081°-63
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSA
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Supt of Building
LOCALITY _
NEAREST l
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER /
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT _ NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP K MAP P /RSO /ES/S-/E�p��BY
CONTRACTOR J
5 1 L' 1
ADDRESS d` CONNECTION DATA
/ STATION / DEPTH
CI 07� TEL. NO.
TATE UPPER
REGISTRATION NO. d [.- O'er ❑ COUNTY MANHOLE REFERENCE
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FR- -rte•
HOUSE SEWER CONNECTING TO $5 OO Q 0 Y. CURB P.L. M.L.TO P.
PUBLIC SEWER , CLV _ P.C.NO. O
SEPTIC TANK,SEEPAGE PIT OR �� NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 0::
PRIVATE DISPOSAL SYSTEM @ $3.00 0
CWONNECT ADDITIONAL BLDG.OR AFFIDAVIT wglvER Eqs EMENT RECORD. INSTR.NO. DATE F
WORK TO HOUSE SEWER @ S3.00 U
OVERFLOW SEEPAGE PIT,DRAINFIELD CLEXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 HWY. OR ST.WIDENING (n
ALTER,REPAIR OR ABANDON HOUSE Z
SEWER OR DISPOSAL SYSTEM @ S3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 21 00
AUTHORIZATION I TOTAL FEE 7Cr
F CONNECTION CHARGE FEE
-IHAVE AT THIS DATE A CONTRACT WITH THE EREIN 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 15 CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS. CESSPOOL ElDRYWELL
IHEREBY 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 gE
I AM THE LEGAL O NER OF, A INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE M IBE E ENTIAL PR ERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILLSEPTIC TANKSOF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
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