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TBA a- APPLICATION FOR PERMIT
COUNTY OF LOB ANGELES SEWER-SEWAGE DIS OSALk
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND 8AFHTY DIVISION ■U ILDING
JOHN A. LAMBIE, COUNTY ENOIN[[R ADDREBS
COLEMAN W. JENKINS. SUPT.OF BUILDING
LOCALITY
NGR[ST
FOR APPLICANT TO FILL IN CROSS ST.
DE4CRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF ALD9S.
SIZE OF LOT NOW ON LOT CITY TIL NO.
USE OF DISTRICT NO. GROUP MAP
WILDING• //��
CONTRACTOR .
ADDRESS 0AJ CO OK DATA
STATION D<TTH
N0.
STAT[ LIC MANHOLE REFERENCE UPT[R
LICK" NO, CEASES �' /
No. DESCRIPTION O WORK FEE TYPR OF CONNECTION LENGTH
MOUSE7EWER CONNECTING TO Y. CURB P.L M.L.TO P.
PUBLIC S4lVDt 41 ie.00 P.C.NO.
SEPTIC TANK. AGE PT CO.IMF.NO. JOB NO.
RA)N FI ELD 41 $10.00
FITS AND/OR D
HOUSE B[WER CONNECTING TO TRUNK PERMIT NO. ROAD rVRMT NO.
PRIVATE DISPOSAL SYSTEM f3.0.0 O
CONNECT ADDITIONAL O.OR AFFIDAVIT I SA""I [AEut[T RECORD.INSTR.NO. DATE U
WORK TO HOUSE DEW[R ff.00
OVERFLOW SEEPAGE PIT.DRAINFIRLD O
E)LTN..CEJISPOOLDRYWELLM,& oL, f0.00
SA ON O HWY.OR Fr.WID[NIN4 1 � W
[R SYSTEM f3.00 STATE KNCROACHMXWr
PERMIT NO.
INDUSTR AL
WASTEAPPROVAL
OWNER'S PSRMrr 51 21 00 CAis
CONNECTION CHA EPEE
AUTHORIZATION I TOTAL FES
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURS[MElfT FEE
LDA
TOR TO,CONNECT THE ASOVE DESCRIBED EXISTING DWELLING
HE PUBLIC •[W�[QR' APPROVALS DATE INSPECTOR'S SIGNATURE
ED THIS-_--1-� Y OF IM
ER OR NEW HOUSE BEWp1
ERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
EI■
122
SEPTIC TANK,SEEP,FIT(S)
EREBY ACKNOWLEDGE THAT,I HAVE READ THIS APPLICATION A-ND/OR DRAINFI[LD
STAT[ THAT THE ABQVK If CORRECT AND AGREE TO COMPLY
ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
BING AND ■[WEBS. CESShOOL ❑ ORYW[ll ❑ERS■Y CERTIFY THAT 1AM PROPERLY RDOISTIEWM AHD/ORALTER.REPAIR.SEWER OR
SED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOGL SYSTEM
ORNIA OR THAT M THE LEG OWN AND I ND TO DISCONNECT PLUG AND
[ IN, TH[ A IB<D ID AL ABANDON HOUSE SEWERATU R[ BACKFILL S[F'U TANKSP[RMTTTE[ SEEP.PIT(B) LJ CESSPOOL)
�IAI.IDATION JACK R. ALLKN
O SUPERVIaINO MECHANICAL EryO1NE[R
„4 9.8 8F NM 1 0 D 5.0 0°,
DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION 812
COUNTY OF LOS ANGELES
t WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS SS C Gf t
FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST
ADDRESS CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
_ A �� S
NEAREST
CROSS ST.ltl�I
T [ RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL
ADDRESS <) .\ USEZONE OCCUPANCY MAP
! I
CITY TEL.NO. "� BK PG
CONTRACTORCalifornia Sealer Ceng _(fin CO.IMP.NO.
ADDRESS 1317 Colegrove Ave- 106 NO. T 7'
CITY Montebello TELAOUNion 7-504,9 TRUNK PERMIT NO.
STATE
REGISTRATION NO.1O4445StMfrtgUNTY
nn T ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. $, �� �. pL/��3 40STATE ENCROACHMENT
n�nAUL � PERMIT NO.
BLOCK TRACT`. s (1 /Wl 1. WADUTRIAL
TEAPPROVAL
3 NO.OF BLDGS.
SIZE OF LOT NOW ON LOT r CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLICSEWER @ $ 3.50 RECEIPT NO. I DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.ORXCEPTION RECORDE
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- DATE
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT ANO ABANDON SEWER
_AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH /
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 Q ANHO ERREFERENCE " R
TYPE OF CONNEETIO�N�.,�� LENGTH FROM 0 /
OWNERS PERMIT $ 1 00 — CtH*& W^` M.L.TO 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 SE E
SIGNED THIS______-_-_ ......_ NEW HOUSE SEWER Q
OWNER OR ,307H C-7'0 /9�• CONNECT ADDITIONAL
OWNERS AGENT... ._.._._.._._....___.._..__..__._.._._.._._..__. ....__....._ BUILDING OR WORK
SEPTIC TANK SEEP.
- - - -...... - -
- AND/OR DRAINF ELD PIT(S)
ADDRESS
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL E] DRYWELL I]
CAT
IONAND 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
1 HEREBY CERTIFY THAT i AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
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
SIGNATURE /�)
OF PERMITTEE-.'�-.Y. — -f-• - -- ------•-- =--•---•---•--•---
76A642D 663 1/53y