HomeMy Public PortalAbout6340 ROSEMEAD BLVD_Sewer__ CE8081D1-57 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL, , '
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
` JOHN A. LAMBIE, Count Engineer ADDRESS
CASSATT D. GRIFFIN, Supt of Building LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. )WNER
BLOCK TRACT MAIL
_ADDRESS
N0.OF BLDGS. I
SIZE OF LOT NOW ON LOT CITY TEL, NO.
USE OF
BUILDINGS DISTRICT N0. GRO_UP MAP
BK PG
CONTRACTOR ,,� .. � "-
ADDRESS CONNECTION DATA
CITY - TEL.NO.;`�'- STATION DEPTH
❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. - ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.50
SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
_ PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL.DRYWELL,MANHOLE @ $2.00 _
HOUSE SEWER CONNECTING TO P.C. NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 _CO.IMP.NO. - JOB N0.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.0 TRUNK PERMIT NO. ROAD PERMIT NO. -
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1.00' STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 1 1 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEEI HAVE AT THI {
CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTDATE A CONTRACT WITH THE IJNGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF f 19 _NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
- OWNERS AGENT - BUILDING OR WORK
ADDRESS "� _ ? .4<. SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
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 _ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. _ BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
OF VALMA71ON ROBERT A. WOOD a
CK. H.0. CASH SUPERVISING MECHANICAL ENGINEER
S& -6°
E631f•5S APPLICATION FOR PERMIT
' •8 '
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL-5
Department of County Engineer
County of LOS Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER I NEAREST
ADDRESS
' ® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT N0.
MAIL
BLOCK TRACT ADDRESS
NO.OF BLDGS. CITY TEL, NO,
SI;E OF LOT NOW ON LOT
USE OF DISTRICT NO. GROUP MAP
BUILDINGS
BK PG
CONTRACTOR
CONNECTION DATA
ADDRESS
STATION DEPTH
CITY TEL.NO.
MANHOLE REFERENCE UPPER
❑ STATE _ LOWER
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE —
HOUSE SEWER CONNECTING TOTYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3.50 Y. CURB P.L. M.L. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00 —
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. NO.
EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $2.00 CO. IMP.N0. JOB NO.
HOUSE SEWER CONNECTING TO
I _ PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT N0. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 _PERMIT NO. _
� ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1,00 INDUSTRIAL
_ WASTE APPROVAL
CHARGES
_ CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00 -
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE F
APPROVALS DATE INSPECTOR'S SIGNATURE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK _
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY —
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE — - ----
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PIT(S)_❑ CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. Y. 0. CASH