HomeMy Public PortalAbout5519 HALLOWELL AVE_Sewer__ DEPARTBIENT OF COUNTY ENGINEER � SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS tlsNGET, S
WILLIAM J. FOX, COUNTY ENGINEER I I BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING ,kms NEAREST
ADDRESS
ADDRESS _) GROSS ST. n�v
LOCALITY / it/ DISTRICT NO. Ready for Inspection PERMIT NO.
NEAREST ' %J • ✓ 13771v- J
CROSS ST. X17_-� .'y]
RECEIVED BY DATE MPED BY DATE
OWNERfl
MAIL USE ZONE OCCUPAN Y MAP
ADDRESS �'� Z �q BK PG
CITY / .Erc�tooti/ L� ±IEINO.
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CONT�A f11 M m /�.: C n_�, v CO.IMP.NO. 54 4y A
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ADDRESS 5933 N. CLOVERI Y AVE, _ ' JOB.NO.
CITY TEMPLE CITY, CAEtF o. TRUNK PERMIT N0.
REGISTRATION NO.
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7CI�i %p ❑ COUNTY ROAD PE` IT NO. /
LEGAL /
DESCRIPTION LOT N0. ✓/�% cf.i� o �/ _ STATE ENCRO MENT
PERMIT NO. �.
BLOCK TRACT • �r�S' ;�T,����! INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT IJ JNO.OF NOW ON LOTS
CHARG
USE OF
BUILDINGS (/�� , CONNECTION CHAR FEE
NO. DESCRIPTION OF WORK FEE
REIMBURSEM T FEE
HOUSE SEWER CONNECTING TO /
PUBLIC SEWER . 0 $ 3.50 RECPT N0. I 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 N0.REPAIR EXISTING 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- �L O� DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
�y UPPER -LOWER
TYPE OF CONNECTIO p- LENGTH FROM /
OWNERS PERMIT I Y. CURB P.L.' M.L.TO P.L. �O
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 THE PUBLIC SEWER 11 /
SIGNED THIS_ _ - DAY OF 19_ f �t .:_Er � ��
�iC� f NEW HOUSE SEWER r 7f z?
OWNER OR ----� 1� �fE^ - CONNECT ADDITIONAL
OWNERS AGENT........... .._--_. BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS._._.---...-_.-...._-._..—.............. ___.—.._.--_—._-._..—.. AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[:] DRYWELL
CA 11
ON 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 IAM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER-OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
�� SEEP.PIT(S)[] CESSPOOLSce
� /
SIGNATURE ��
OF PERMITTEE_
76A642D S&.E 663 4/54 C i