HomeMy Public PortalAbout5551 GRACEWOOD AVE_Sewer__ 25
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76A APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELRS SEWER—SEWAGE DIS OSAL
DtrARTMENT OF COUNTY QNGINZKR
BUILDING AND SAFETY DIVISION ■uILOINo
JOHN'A. LAMSIQ, COUNTY ENGINEER A.
COLEMAN W. JENKINS. SUPT. OF BUILDING
)_OCALfI"1'
NEAREST
LIEGAL FOR APPLICANT TO FILL IN CROS. ST.
DLdCRIPTIom LOT NO. OWNER
F MAIL
BLOCK TRACT _S ADDRESS
NO. OF SLOG■. !
SIZE OF LOT NOW ON LOT C TEL NO.
U.L OF
■UIL.DINOS DISTRICTGROUP MAF SY
A ■K M
CONTRACTOR I �� oo
ADDRESS .(_/ O DAT
CITY 1-D TLL. NO. _G RATION DETTH
STATE CEHEE NO. t. �� �/ MANHOLE REFERENCE U"R
No. DESCRIPTION OF WORK FE[
TYPE of coNNEcT1oNSTH FrJN
Gr*-"■ECQNNECTINO TO Y. CURB P.L- be.L-TO P.
PUBLIC SEWER 0 $17.00 P,G.MO.
■ IC TANK. AGE PIT CO.IMP.NO. JOY NO.
7
P17AND/OR DRAINFI[LD $10.00
HOUSE SEWER CONNECTI NO TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL SLDC11.OR AFFIDAVIT SA71n lAl ERI.T RECORD.INSTR.NO. DATE S
WORK TO HOUSE SEWLR 57.00
OVERFLOW SEEPAGE PIT.DRAINFIELD C
EXTN..CESSPOOL.DRYWK" MANHOLE 0 5111.00 1--'
A HOLISM HWY.OR ST.WIDILNING U
W
S[W[R ■YIIT[M E.00 STATE LNCROACHMEHT p_.
PERMIT No. r C7
INDUSTR AL
WASTE APPROVAL
�T�OWNM'S PEEA�QT' • Y 00 c Ra
AV HORMATION TOTAL CGN NECTIDN CHA E FEE
I O
HAV[ AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CM. REI M■URST EMENFEE
TRACTOR rcLcom NLCT THE ABOVE DLSCRI■ED [EISTINO DWELLING ��VF� �l T�
TO THE PUBLIC 6"p. APPROVALS DATE IN■TECTOR'S SIONATURE
SIGNED THIQ DAY OF I9-1k
OWNER OR NEW HOUSE SEWER
OWNERS A9ENT
ADDRESS JV CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK.SEEP.PITS)
1 HEREBY ACKNOWLEEP
DOK THAT.1 HAVE RAD THIS APLICATION A-ND/OR DRAINF1[LD
AND STAT[ THAT THE ABOVE IB CORRECT AND AGREE TO COMPLY
Y
WITH ALL COUNTORDINANCE- AND STATE LAWS REGULATING
PLUMBING AND S[WEFS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM P*OPLRLY REGISTERM AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REOUIR[D S ANOLU COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I A LEGAL AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO V[ D I [D RUED PROP[ ADAM DON HOU.[SEW[R
■IOF APERMITTEE BACKFILL.EPTJ_C TANKS El■EES.PIT(.) U C[1S1-OOLS
/ VALIDATION JACK R. ALLSN
l J
Y.O. CA.H SUPERVISING MECHANICAL ENGINEER
GK.
I ,
� '�,499die H91910 0 5.0.0 V
1)EPAlVr3 !7T OF OOUNTY ENCLM:M SEWER-SEWAGE DISPOSAL $ 1
' DIVISION OF BUII.DING AND SAFEYY PERMIT APPLICATION
OOUNTY OF LOS ANGIST,
WILLIAM J. FOX. COUNTY ENGINEER ADDRESS J
FOR APPUPAW TO RLL IN LOCALITY
BUILD NS NEAREST
ADDRESS CRM
LOCALITY DI$TN10T NO. GENIAL M0. PERMIT M0.
MEARE8T \ A
CROSS ST. RECE ED R.adY tW I2209etly DATE ISSUED
OWNER 60
MAIL � � USE ZONE OCCUPANCY MAP
ADDRESS
� BK PS
CITY TELNO.
COMTRACTOCalif ornia Sewer Const.CO. CO.IMr.No.
ADDRESS 1317 Colegrove Ave. JOB No. i
CITY Montebello TELMUNion 1-644$ TRUNK PERMIT NO. -------
STATE
REGISTRATION NO].04445 StaQlOUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. STATS ENCROACHMENT
9 PERMIT M0.
p2 D J
BLOCK TRACT S r �p INDUSTRIAL'
WASTE APPROVAL
SIZE OF LOT D� NOW OM LOTS CHARGES
USE OF
BUILDIN85 _� DONMEOTION GE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER 0 !i 3.31 RECEIPT NO. ATE BY
HOUSE SEWER CONNECTING To
PRIVATE DISPOSAL SYSTEM I.M
CONNECT ADDLTIONAE BL IL OR EXCEPTION RECO
WORK TO HOUSE BEWER 1.00
ALTER OR REPAIR G NO. DATE
SEWER OR DISPOSAL SYSTEM 10�
DISCONNECT AND ABANDON SEWER
AND OR DISPOSAL SYSTEM I." CONNECTION DATA
PTIC TANK,SEEPAGE Ptt OR
PITS AMD/OR DRAIMFIELD 2.90 8TATION * DEPTH
SPECIAL OONOITIOMS ONLY !.M / MANHOLE REFERENCE
3 -/. UPPER
TYPE OF COMM CTI LENGTH FROM
OWNERS PERMIT I 00 'T L'LTRB- P.L M.L TO P.L. d
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO T+�HEE PU LLIO SEWER L
SIGNED THIS S30 -DAY 19ST NEW HOUSE$EWER
OWNER ` CONNECT ADDITIONAL
OWNERS BUILDING OR WORK
SEPTIC TAM SEEP.PIT($)
ADDRESS AMD/OR ORAINFIELD
y 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APFLI- CE881-00L[:] DKYWELL E]
DATIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTERR,REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS. aEWAAE DISrO>{IAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTYUSE AND
DISCONNECT ABANDON HOPLUG PLUGAND 1
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
EQ OF THE ABOVE DESORIBED RESIDENTIAL PROPERTY. BAOKFILL 89PTiO-TANKS
SIGNATURE SEEP-PLT(3)Ei CESSPOOLS
OF PEBMITTEE _! I MAI-
y
f6A64iD 6�3 1/63 A vf�