HomeMy Public PortalAbout10709 GRAND AVE_Sewer__ DEPART TENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDINGNEAREST
ADDRESS 10709 Grand Avenue CROSS ST.
LOCALITY 191 Monte DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST FA A S
CROSS ST. Rl Unm@ AyA-
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER P*L• MONutt
MAIL
ADDRESS 2721 San Gabefil Blvd, USEZONE OCCUPANCY MAP
$ BK PG
CITY San Gabriel TEL.No. AT 94364
CONTRACTORLQ. & M, Construction Coo CO.IMP.NO.
ADDRESS Wnth•n Tr,-
408- i
,r , ate 106 No.
CITY AI hqni'h-rrL TEL-NO- j�T dARI 5 TRUNK PERMIT NO. -. - --
STATE
REGISTRATION NO. 113613 C 42 R COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. 56 STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT 17867 INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS.
NOW ON LOT CHARGES
USE OF
BUILDINGS Rg3� CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING To REIMBURSEMENT FEE
1 PUBLIC SEWER i 3.50 RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- I DATE BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/ORDRAINFIELD 2.00 STATION - DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 f• MANHOLE REFERENCE
UPPER
TYPE OF CONNECTION LENGTH,E&OM
OWNERS PERMIT $ 1 00 Y. CURB P.L. 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
DWELLING TO THE PUBLIC SEWER APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS--------------------DAY OF------------_.................._......19NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT............................................................................ BUILDING OR WORK
ADDRESS----------------------------------------------------------------- - - - SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[] DRYWELL
CATION AND 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
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT ABANDON HOPLUG PLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RE$IDENTIAL,PR�OtPERTY. BACKFILL SEPTIC TANKS Ej
SIGNATURE �� / SEEP.PIT(S)E] CESSPOOLS❑
OF PERMITTEE.-.r
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