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S&E 6D APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los AngelesBUILDIN
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JOHN A LAMBIE COUNTY ENGINEER ADDRESS 551-C, Fpla' e0
CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
NEAREST "it$ �
FOR APPLICANT TO FILL IN ceoss srFrP r St.
DESCRIPTION
LEGAL LOT NO C.1 12 OWNER UT. B. 17eber COP_s Glu C GiOn CO
MAIL ��, I
BLOCK TRACT 2y 389 ADDRESS 2721` San Gabz�iel Blvd.
NO OF BLDGS CITY TEL NO AT 0 1
SIZE OF LOT NOW ON LOT G i le 1 — 53
USE OF
BUILDINGS Resp dente DISTRICT NO GROUP MAP
T�
1 PG
CONTRACTOR L. D. �� P11. Gonstruc-cion �j �— _ 1
J_V
�T S CONNECTION DATA
ADDRESS B1 eecker ,,7Ti • P
CITY TEL NO FD 8-3024 STATION DEPTH
Baldwin Park MANHOLE REFER NCE
STATE OWER
REGISTRATION NO 113613 o COUNTY
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE OF CONNECTIO LENGTH FROM
,e z Y CURB P M L TOP L
PUBLIC SEWER @ $35p W
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $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 @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER S PERMIT $ 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER Q
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER ORBUILDING OR WORK
OWNERS AGENT NeW SEPTICTANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
1 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 SEWEROR
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 CO Y AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL NE OF THE ABOVE
DESCRIBED RESIDENT P Y BACKFILL SEPTIC TANKS❑
SIGNATURE — SEEP PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A LAMBIE COUNTY ENGINEER TOM ALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
�K �A5 7 6 9
C ,P OCT 15 10 A 5 4 0