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HomeMy Public PortalAbout6320 ROSEMEAD BLVD_Sewer__ 7 -64 6A642D APPLICATION FOR PiERMI YL6A642 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS WILLIAM A. JENSEN, Sup't of Building LOCALITY CROSSJST. IL h FOR APPLICANT TO FILL IN LEGAL DESCRIPTION LOT NO. OWNER L MAIL BLOCK TRACT ADDRESS NO. OF BLDGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF BUILDINGS DISTRICT NO. G/OUBK UP MAPP �j PROCEEDS/SED BY CONTRACTOR 'el I +�.. J t! I �� l✓ l '� kj ADDRE S5� CO NECTION ATA CITY,/__3> t-CC[Z—OW EL. NOSTATION DEPTH STATE MANHOLE REFERENCE UPPER REGISTRATION NO. f G COUNTY LOWER 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 @ $5.00 P.C.NO. SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. D_ HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O PRIVATE DISPOSAL SYSTEM @ $3.00 CONNECT ADDITIONAL BLDG. AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO, DATE t 'TO HOUSE SEWER @ $3.00 O OVERFL73 OW SEEPAGE PIT,DRAINFIELD 1-- EXTN..CESSPOOL,DRYWELL.MANHOLE® $5.00 V ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING SEWER OR DISPOSAL SYSTEM @ S3.00 STATE ENCROACHMENT r N PERMIT NO. Z INDUSTRIAL WASTE APPROVAL CHA GES OWNER'S PERMIT s 2 00 AUTHORIZATION TOTAL FEE , 6p-o CONNECTION CHARGE FEE '1 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 INSPECTO 'SSI G NATURE SIGNED THIS DAY OF 19_ � OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK PIT(S) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP, AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY GISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSED AS REQUIRED BY LOS ANGLES C UNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I A E LEGA OW RSO F, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABO DESCR SIDE TIAL PROPERTY. ABANDON HOUSE SEWER SIGNATURE OF PERMITTEE s? BACKFILL SEPTIC TANKS El SEEP,PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT A. WOOD CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER j .61 0 1Z8 NOV 30 1 0 5.00 76A,6'4213 CE ©5 808(REV.6/781 APPLICATION FOR PERMIT SEWER - SEWAGE DISPOSAL COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP PR CESSED BY-3- Y BUILDING PG ADDRESS -3- {J LOCALITY Te PV-_ )� �i"� CONNECTIO DATA NEAREST /a q STATION DEPTH CROSS ST. C' UPPER MANHOLE REFERENCE LOWER OWNER TYPE OF CONNECTION LENGTH FROM MAIL Y. CURB P.L. M.L.TO P.L. ADDRESS P.C.NO. CITY TEL.NO. CO.IMP.NO. JOB NO. LEGAL TRUNK PERMIT NO. ROAD PERMIT NO. DESCRIPTION LOT NO AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR,NO, DATE BLOCK T ACT LZN NO.OF BLDGS. SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING USE OF BUILDINGS STATE ENCROACHMENT -e qpy� , _ PERMIT NO. �. CONTRACTOR A a iL r Q Pe- e. G k INDUSTRIAL WASTE APPROVAL ADDRESS CHARGES Q �s CONNECTION CHARGE FEE OF CITY 8 IA.$SIX l}. P6-y.k TEL.NO. 1; `Q-C)#4 3(o STATE ( LIC. REIMBURSEMENT FEE LICENSE NO. V p'31 CLASS C NO. DESCRIPTION OF WORK FEEO APPROVALS DATE INSPECTOR'S SIGNATURE HOUSE SEWER CONNECTING TO oL"� PUBLIC SEWER O NEW HOUSE SEWER SEPTIC TANK.SEEPAGE PIT OR O PITS AND/OR DRAINFIELD CONNECT ADDITIONAL � HOUSE SEWER CONNECTING TO BUILDING OR WORK PRIVATE DISPOSAL SYSTEM CONNECT ADDITIONAL B6961:2DR. SEPTIC TANK.SEEP.PIT(S) WORK TO HOUSE SEWER AND/OR DRAINFIELD o OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ❑ DRYWELL E)EXTN..CESSPOOL.DRYWELL,MANHOLE ALTER.REPAIR OR ABANDON HOUSE ALTER.REPAIR.SEWER OR SEWER ORD ISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER BACKFILL SEPTIC TANKS❑ OWNER'S Permit $ SEEP.PIT(S)❑ CESSPOOLS❑ AUTHORIZATION TOTAL FEE U �r � VALIDATION I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- C TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TOTHE PUBLIC SEWER. /� R ry SIGNED THIS DAY OF 19_ ' Q6 / A OWNER OR OWNERS AGENT �.� oo,00yfl ADDRESS IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 2.0 O I C o o AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING 'O O O O 0 PLUMBING AND SEWERS. I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED BY LOS ANGELES OUNTY AND STATE OF q ht;40 CALIFORNIA OR THAT I AM THE LEGAL OWN E F.AND INTEND TO R 0(E- . v SIDE IN.THEABO RIBED RESIDENTI ROP RTY. SIGNATURE OF PERMITTEE