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DEPA1trMENT OF COUNTY ENGINEER ( SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY jl PERMIT APPLICATION
COUNTY OF LOS ANGELES �
WILLIAM J. FOX. COUNTY ENGINEER BUILDING /
ADDRESS Q (p 3
FOR APPLICANT TO FILL IN J LOCALITYBUILDING NEAREST
ADDRESS 10631 IRairhall St• CROSS ST
LOCALITY 'Temple City DISTRICT NO SERIAL NO q PERMIT NO
NEAREST 5-CROSS ST Ll MOI)t a Ave. A // S�T'Z�
RECEIVED BY Ready for Inspection DATE ISSUED
OW'NERP• L• Me Nutt I / /l�e14 . 7z
MAIL
ADDRESS 279i Sari Gabrid3. Blvd• USE ZONE OCCUPANCY I BK MAP PG
CITY San Gabriel TEL NAT 94364 I - I N24
CONTRACTOR,-,iL*D. & Mo Constr. Co. CO—AMP.-NO e
ADDRESS 21 vis Wistaria Ave. j 5-�
JOS NO (p
CITY Arcadia TEL NO EO 6 2238 TRUNK PERMIT NO
REGISTRATION NO 113613 ^ C - 42 B�STATE \
COUNTY ROAD PERMIT NO 1
LEGAL s'
DESCRIPTION LOT NO STATE ENCROACHMENT
i� PERMIT NO
BLOCK TRACT 19189 INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO OF BLDGS
NOW ON LOT 9 CHARGES
USE OF
BUILDINGS ReS• & Garage CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
1 PUBLIC SEWER @ $ 350 —3 30 RECEIPT NO I DATE' BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00 `
CONNECT ADDITIONAL BLDG OR EXCEPTI!PN C RDED
WORK TO HOUSE SEWER 1 00 NO I C I
ALTER OR REPAIR EXISTING � eDATE BY
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1 00 1 CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR /
PITS AND/OR DRAINFIELD 200 STATION Dt�Lf a DEPTH (�
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 / MANHLER REFERENCE C LOWER
I ` TYPE OF CCO1 00 RNNECTIONP ET OAV
OWNERS PERMIT L L� ML P L
AUTHORIZATION I TOTAL FEE $ 4 50
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING '
DWELLING TO THE PUBLIC SEWER APPROVALS INSPECTOR'S SIGNATURE DATE
I
_ __ 19___ NEW HOUSE SEW ER
SIGNED THIS DAY OF :5
OWNER OR J CONNECT ADDITIONAL
OWNERS AGENT _ _ _ _ BUILDING OR WORK
SEPTICTANK SEEP PIT(S)
ADDRESS - 1 AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI CESSPOOL[-] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWSt ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS i SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED f 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 BACKFILL SEPTIC TANKS❑
' SEEP PIT(S)I] CESSPOOLS E]
SIGNATURE
OF PERMITTEE IA. Fj �iliv,/-Cibi/.�3��,s/ • - ' i �y
76A642D 663 1/53