HomeMy Public PortalAbout10629 HALLWOOD DR_Sewer__ IDEPAICrAMNT OF COUNTY ENGINEERI SEWM-SEWAGE DISPOSAL,
DIVISION OF. BUILDING AND SAFETY _ I PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J.-*OX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LocaLiTv
ADORE
BUILDING NEAREST
ADDRESS 1062q TiAl lLvoO�' T CROSS ST.
LOCALITY gYTlplB City SICDISTRICT NO. SERIAL NO. PERMIT NO. c
NEAREST A l / ��LF - �'J
CROSS ST. El,Llont a Ave a
RECEIVED BY Ready for Inspection h DATEISSUED
OWNER P.L. 114C Nutt
MAIL
ADDRESS .2.72'2 $an Gabriel Blvdo U5EIONE OCCUPANCY I MAP
• BK _PG'
CITY San Gabriel TEL.NO, At. 94364 —
CONTRACTOR L.D. &- M. Constr. Coo C ,� ��
O,I MJ3.LI0.
ADDRESS 21 'rd. listaria Aw . /
JOB N0.
CITY Arcadia TEL.NO. }gip 62238 TRUNK PERMIT NO.
STATE
REGISTRATION NO. 11.3613 C 42 COUNTY ROAD PERMIT N0.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO-74STATE
NO.
BLOCK 'TRACT 19189 INDUSTRIAL /
� WASTE APPROVAL
NO.OF BLDG&. �
SIZE OF OT NOW ON LOT CHARGES
USE OF
BUILDINGS Res. & Garage CONNECTION CHARGE FEE \
NO. DESCRIPTION OF WORK FEE
1 HOUSE SEWER CONNECTING TO 5V REIMBURSEMENT FEE
3
PUBLICSEWER Q $ 3.50 J RECEIPT NO. DATEBY
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 N0. I \D TE 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 o 1 , 0 DEPTH 6 '
CESSPOOL—DRY W ELL
SPECIALCONDITIONS ONLY 2.00 !-� / MANHOLE REFERENCE ,�/ LOWER
TYPE OF CONNECTION LENGTH FROM L /
OWNERS PERMiT $ I 00 CUffe- P.L. M.L.TO P.L. L S
AUTHORIZATION I TOTAL FEE
4-
I
HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS I NSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS-------------------DAY OF................_......................19...... NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWN ERS AGENT....-------------- --------------------------••---------------------- BUILDING OR WORK
-------- -------------------------------------------------- SEPTIC TANK,SEEP.PITS)
ADDRESS-----------------------------------
AND/OR DRAINFIELD
I 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 I 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 RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURESEEP.PIT(S)Ej CESSPOOLS ElOF PERM IITTEE.-.__.Lo_Da---1-.- a_.VQ 'a_..�c
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