HomeMy Public PortalAbout5121 ROSEVALE DR_Sewer__ CAC4aQSto-0] APPLICATION FOR PERMIT
7E
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDINo /Zi OSENf}/- I)
TfORN A LAMBIE CoEn BY ADDRESS
WNJ.IAM A IENSEN SrvD f of D...id—v
LOCALITY
NSAR[GT
FOR APPLICANT TO FILL IN
DCBDRIrr1ON LEDLOT NO �7 OWNER G,-,H 17 K0
MAIL y
BLOCK TRACT ADDRESS
NO OP BLDOB ,
SIZE OF LOT NOW ON LOT CITY PL_,f / T[L NO
03E
OF
BUILDINGS DISTRICT NO I OROUR 4 MAP Eee[G BY
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11K pa
CONTRACTOR ff,4 �a" A�'� j _r J T16 1
ADDRESS ,� }�Li V G dam' CONNECTION DATA
CITY �ll Y[I IV D [L NO RATION O[PTX
REGISTRATION NO 43o A/
,�f/�� j.4 CSTATE Y
MANHOLE REFERENCE UPPER
l
COUNT
NO DESCRIPTION OF WORK FEE BOF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO CURB PL M L TO P L �� a
PUBLIC SEWER C SB OO OD
SEPTIC TANK SEEPAGE PIT OR P` NO
O
PITS AND/OR DRAINFIELD C SI°OO CO IMP NO JOp NO S V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PGMR NO ME
PRIVATE DISPOSAL BYSTEM 0 E9 Go
CONNECT ADDITIONAL BLDG OR AFFIDAVIT R4T(( I"IR(R( RECORD INS" NO DAT[ O 0
WORK TO HOUBESKWER Y 3 G tS,j
OVERFLOW SEEPAGE PIT GRAINFIELD
E%TN CESSPOOL DRYWELL MANHOLE Y $5 00
ALT R REPAIR OR NDON OUS HWY OR ST WIDENING y
BC p plp S SYETE 0 SS STAT[[NCROACXM[NT Z
FERMIT NO
INDUSTRIAL
OWNERS PERMIT s x 00
WAST[APPROVAL
CHARO[S
AUTHORIZATION TOTAL FEE OO CONNECTION CHARGE F[[
1 HAVE AT THIS DAT[ A CONTRACT WITH TH[ HEREIN NAMED CON REIMBURSEMENT FE[ O `�
TRACTOR TO CONNECT HE ABOVE DESCRIBED EIISTING DWELLING APPROVALS
TO THE PUBLIC BE
DAT[ INSPECTOR S SIGNATURE
SIGNED THIS DAY 0FI90 b _
OWNER OR NEW HOUECTAD EWER
OW ME"AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SCPTICTANK BEEF PITIS)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATC THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE "WE REGULATING
PLUMBING AND EEWERB CESSPOOL ❑ DRYWCLL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR BEWEROR
LICENSED AS REOUIRED SY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIF°RN IA OR THAT I AM THE LEGAL OWNER OP AND INTEND TO DISCONNECT PLUG AND
RIDE IN THE ABO DESCRI R[/I TIAL PROPERTY
ABANDON HOUSE SEWER
SIONATUR[
OF PCRMITT[[ BACpF ILL BTANKS ❑
S[CP PIT(B)
0 C[1tPO0U
GALMATION ROBERT A WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
j,,,p 4 3 8 6`a PUG 5 1 0 D 7.00-
• COUNTY OF LOS ANGELES TEMPLE CITY 8 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC MORES 9701 LAS TUNAS BE 0508 0603090005
BUILDING AND SAFETY / LAND DEVELOPMENT TALE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL ID SEIBH SEPTIC SRMER BUILDING ADDRESS
TR 39316 BAST OCC G" 5111 ROSEVALB DR
BLDGS HON ON LOT TEP CA 917803308
ASSESSOR INFORMATION NUMBER CONNECTION TYPE NEAREST CROSS STREET
ORIGINATION THOMAS PAGE GRID LOCALITY TEMPLE CITY, C
LENGTH ML TO PL STATION DEPTH
TENANT MANHOLE REFERENCE UPPER/LOWER ISSUED ON PROCESSED BY EXPIRES ON
03/10/06 JK 09/06/06
COUNTY IMPROVEMENT NUMBER
OWNER TEL NO PLAN CHECK NUMBER FINAL 9ATEeL_ PIN MDR
PASTOR, MANUEL (626) 482-1382- JOB NUMBER
/ r
5121 ROBHVALB DR TRUBX DSHMIT NUMBER
TEMPLE CITY 91780 ROAD PERMIT NUMBER DESCRI PTION PTO WORK
APPADAVIT NO CONNECT NEW RESIDENCE TO PU LIC SENSE
WAIVER NO
APPLICANT TEL NO BASEMENT NO
CHEM (616) 454-9555-
1517 S 8TH STREET RECORD INSTRUMENT HER RECORD DATE SPECIAL CONDITIONS
ALHAMBRA, CA 91803 HIGHWAY/STREET WIDENING
STATE ENCROACHMENT PERMIT NUMBER
CONTRACTOR TEL NO FEES PAID APPROVALS DATE INSPECTOR SIGNATURE
PASTOR, MANUEL (626) 285-4159-
9237 BLACXLSY ST LIC NO PEE DESCRIPTION QB ITY UOM AMOUNT NEW HOUSE SEWER
TEMPLE CITY CA 91780 NOBS
01 PERMIT ISSUANCE PEE 27 75 CONNECT ADDITIONAL
03 CONN TO PUBLIC SEWER 1 00 CON 46 95 BUILDING OR WORK
ARCHITECT OR ENGINEER TEL NO TOTAL FEES 74 70
CH ' CHARLES (626) 454-9555- SEPTIC TANK SEEPAGE PIT
1517 S 8TH STREET LIC NO AND/OR DRAIN FIELD
ALHAMBRA, CA 91803 C 019359
DRYWRLL
SEWER MAP BOOK PAGE ALTER REPAIR SEMEN OR
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEIBR
BACXPILL SEPTIC TANKS _
SREP PIT CESSPOOL
GRAYWATER SYSTEM
REPORT ID DPR266 ROUTS TO BS0508