HomeMy Public PortalAbout5626 GRACEWOOD AVE_Sewer__ DEFA rnkDMW OF OOUNTY EN(DNEEE SEWER—SEWAGE DISPOSAL 8 0 9 Z
n DMSION OF BDa.DING AND SAFETY PERMIT APPLICATION
OOUNTY OF IAS ANGELES
WILLIAM J. FOX, cnurrnr ENDIINCIR ,ADDRESS
FOR APPLJCpANT TO FILL IN LOCALITYBUILDING
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ADDRE88 OLC� C
6ROSSST
di ST.
LOOALrTY O"rmOT NO. EEGIAL K0. PERMIT R0.
NEAREST //��L.rJ S
C11088 ST • 'REORIVED
/BAY Ibao tw Im"ed a DATE 133IJKD
OWNER
NAIL USE ZONE OCCUPANCY MAP
ADDRESS BK PG
CITY TE -NO. A -
/ 6_� - I
CONTRACTOR California Surer Const.Co. GO,IMP.ND.
ADDRESS 1317 Colegrove Ave. A IDB NO.
CITY Montebello TELNOUN1on 1-5048 TRUNK PERMIT NO.
REGISTRATION NO.1044415 S ANTS ROAD PERMIT NO.
LEGAL A STATE ENCROACHMENT
DESCRIPTION LOT N0� PERMIT NO.
BLOCK TRACT , WEE APPROVAL
SIZE OF LOT /� Y0.OF BLD GS
G/ NOW ON LOT CHARGES
USE OF
BUILDIN68 CONNEOTIO CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIYBURSEMEN
I PUBLIC SEWER • i L." RECEIPT NO. 'DATE BY
HOUSE SEWtfi tONkrfflNGTO
PRIVATE DISPOSAL SYSTEM I."
CONNECT ADDITIONAL BL IL OR E)(CEPTION RE ED
WORK TD HOUSE SEWER I.M
P NO. DATE Y
SEWER OR DISPOSAL SYSTEM I m
DISCONNECT AND ABANDON BEWER
AND/OR DISPOSAL SYSTEM 1.60 CONNECTION DATA
SEPTIC TANK,8 E PIT OR
PITS AND/OR DRAINFIELD LM STATION DEPTH
SPECIAL CONDITIONS ONLY 2.WY HOLE REFERENCE
UPPER
TYPE OF CONNfi i LENGTH FROM /
OWNERS PERMIT $ 1 CO C°FM P M.L TO P.L I '
AUTHORIZATION 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 PL}BLIO SEWER
SIGNED THIS 3� DAY)F 1 .� NEW HOUSE SEWER G -
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP.PIT(8)
AND/OR OR NFIELD
1 HEREBY ACKNOWLEDGE THAT r HAVE READ THIS APPLI- CESSPOOL[:] DBYWELL[c]CATION AND STATE THAT THE ABOVE 18 CORRECT AMD AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEIVERB SEWAGE DIVOROL SYSTEM
1 HEREBY CERTIFY THAT I AN PROPERLY REOISTERED DISCONNECT PLUG AND
AMD/OR LIOENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AN THE LEGAL OWN-
ER OF THE ABOVE DESCRIBE RESIDENTIAL PROPERTY. AM
IGNATURE EEEP.PIT(S)o CE88POOL� ` — S
i
OF PERMITTE
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