HomeMy Public PortalAbout10721 GRAND AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING 10721EAREST
ADDRESS Grg3n 1 Ave-Ave_ CROSS ST.
LOCALITY 191 MonteDISTRICT NO. SERIAL NO. PERMIT NO. C
NEAREST Bl M�Tlte Av®• A S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER P. L• MONUtt
MAIL 27
__-
ADDRESS 27242-,San Gabriel Blvd. USE ZONE OCCUPANCY BK MAP PG
CITY San GabrielTEL.NO. AT 94364
CONTRACTOR L,]).& Mo CONSTRUCTION C01 CO.IMP.NO.
ADDRESS 408 Winthrop Tira JOB NO.
CITY Albambr a TEL.NO. AT 483155 TRUNK PERMIT NO.
STATE
REGISTRATION NO. 113613 Ci 42 COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. 558 PERMIT NO.
BLOCK TRACT 17867 INDUSTRIAL
WASTE APPROVAL
SNO.OF BLDGS.
SIZE OF LOT
NOW ON LOT `L CHARGES
USE
BUILDDINGS 1 Re8 CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER (t$ $ 3.50 RECEIPT NO. I DATE (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 I 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/OR DRAINFIELD 2.00 STATION f `� DEPTH ,'8 •• f�
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 ^ ' MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTIONLENGTH FROM
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 APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS--------------------DAY OF........................................19....... NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT............................................................................ BUILDING OR WORK
_-----_------__ SEPTIC TANK,SEEP.PIT(S)
ADDRESS_________
----•------------------_----------------------------------- AND/OR D RA I N F I E L D
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL Ej DRYWELL F]
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
1 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-
USE SEWER
ER OF THE ABOVE DESCRIBED REST EAITIAL PROPERTY.. BACKFILL SEPTIC TANKS
r SEEP.PIT(S)o CESSPOOLS
SIGNATURE ,�%Ir' �.�_-r
OF PERMITTEE__. e/.:
76A642D 663 1/53