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9&E-663
6APPLICATION. FOR PERMIT
8DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
'Depoxhnent of County Engineer '
\ County of Los 'Angeles BUILDING 9568 Br®Qdway
i JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN. SUPT OP BUILOIMG LOCALITY Temple Cit .
FOR'APPLICANT TO FILL IN
NEAREST T. .
LEGAL a OWNER Jack Henne
DESCRIPTION LOT NO. �^' �f' Y
BLOCK TRAcr�IQQ)f (I �,u,.,j no cess 121' Highland Oaks
NO. OF BLOTS. CITY Arcadia TEL. ND, HI-62786
SIZE OF LOT _ NOW ON LOT
.j
USE OF
BUILDINGS Residence DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR 1. Parker Plumbing � � Jdr S 3(
ADDRESS 1461/ E. Ramona Blvd. CONNECTION DATA
CITY Baldwin ParkTEL. NO.EL-1127 MON__ON'_ DEPTH -
0
ENCE _ UPPER
REGISTRATION N0. 197747 * - ❑ STATE LOWER.
COUNTY
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF ONNECTION LENGTH FROM--
PUBLIC SEWER @ S 3.50 Y. URB P.L. M.L. TO P.L.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ S 3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD P. C. NO.
EXTN..CESSPOOL,DRYWELL MANHOLE @_ $2.00 Co. IMP. NO. JOB NO. -
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM. @ S 1.00 TRUNK PERMIT NO. ROAD PERMIT-NO:'
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 AA .PERMIT N0. '
RIAL
5 WER ORS SE @' QV WASTE INDUSTAPPROV '
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT Y 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE I
Q _APPROVALS DATE INSPECTOR'S SIGNATURE
1 HAVE AT THIS GATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER - a
SIGNED THIS DAY OF J9_ CONNECT ADDITIONAL
OWNER OR' BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY,ACKNOWLEDGE THAT 1 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 pLTFp REPAIR,SEW ER.OR n
PLUMBING AND SEWERS. �• •�� ^^^� ^^^^� O1
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICE14SED AS REQUIRED BY LOS ANGELES COUNTY STATE OF ABANDON HO PLUGAUSE D
CALIFORNIA OR THAT I. AM TH LE L OWN F E ' OVE
DESCRIBED RESIDENTI PE BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PHIS) ❑ CESSPOOLS❑
OF PERMITT /
JOHN A. LAMBIE, COUNTY ENGINEER /y/ALIDATION ROBERT A. WOOD. CHIEF PLBG. INSPECTOR
M.0. CASH
LAUO 3 9.4' FEB 26 1 0 D 5.00-
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