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DEPAWrMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
Y
FOR APPLICANT TO FILL IN LOCALITY 6� ))AO ';I-e,
BUILDING NEAREST
ADDRESS torr � rrOW00(i St o CROSS ST. ✓
LOCALITY El Monte - DISTRICT NO. /SEERRIIAL NO.. .cPPERMIT NO.
NEAREST a•f o� A(� O.2 f� ld�5':�&YJ
CROSS ST. BI Monte Ave o
RECEIV D BY Ready for Inspection DATEISSUED
OWNER P, Le Mr.NuttMAIL
ADDRESS 272J- San Clqbrlel Blvd o USE 6NE OCCUPANCY BK MAP PG
CITY San Gabriel TEL.NoAT 94364
CONTRACTO RL, Do & Mo Constraation Coo
CO.IMP.N0.
ADDRESS 408 Winthrop Dr o JOB NO. � xv d--A
CITY Alh=bra TEL.NO. AT 48315
TRUNK PERMIT N0.
STATE
REGISTRATION NO. TTM ,,t C 62 [ COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. 3$ PERMIT NO. `
BLOCK TRACT 17867 INDUSTRIALA
WASTE APPROVAL 1 \
NO.OF BLOGS.
SIZE OF LOT NOW ON LOT 1 �3 BH ARG ES
UOF
BUE DINGS 1 Read \
CONNECTION CHARGE FEES
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
1 PUBLIC SEWER @ $ 3.50 RECEIPT NO. I DATE`S I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED.,
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING 0• I DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00 "+
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR tl
PITS AND/OR DRAINFIELD 2.00 STATION ¢®� DEPTH
CESSPOOL—DRYW ELL
SPECIAL CONDITIONS ONLY 2.00 // fi MAN=IREFERENCE LOWER
TYPE OF CONNECTION LENGTH_EROM—
OWNERS PERMIT $ I 00 'x� CU.RB� P.L. M.LrTO`P:L.
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS-------------------DAY OF........................................19.... NEW HOUSE SEWER I'd 7_
d7_—
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT......................................................_.............. BUILDING OR WORK
ADDRESS........................................................ SEPTIC TANK,SEEP.PIT(S)'
--�•----••---------•----•••-----•- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[:] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT J AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
; ER OF THE ABOVE DESCRIBED RESIDENTIAL-PROPERTY. BACKFILLSEPTIC TANKS
�
SIGNATURE
���,,� � SEEP.PIT(S)[-] CESSPOOLS E]
OF PERMITTEE-•��- - -- r�----- ---- -._._.-....-----•---...--••----
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