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76A64 fo.ez APPLICATION TION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building j
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT 91L19
ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF .. .. ._ ,. ..
BUILDINGS DISTRICT NO. ROU MAP 4 PROCESSED BY
CONTRACTOR �T'{,/�, `I �-5 (/ B_ ! 2 rsT I
ADDRESS CONNECTION DATA
CITY TEL. NO. STATION DEPTH
❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM }
CL
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. O
PUBLIC SEWER. @ $5.00
P.G.NO.
SEPTIC TANK,SEEPAGE PIT OR fJ
CO.IMP. NO. JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 �
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL' /#.f'j AFFIDAVIT I WAIVER [nSEMENT RECORD.INSTR.NO. DATE W
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD h
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 Z
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO..
INDUSTRIAL
WASTE APPROVAL ` , �LP✓l.
OVWER'S PERMIT $1 2f 00 CHA ES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DES RIBED EXISTING DWELLING
TO THE PUBLIC SEWE APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 1941
OWNER OR NEW HOUSE SEWER jI „
OWNERS AGENT CONNECTADDITIONAL 7
BUILDING OR WORK �' h 6'-/•r, .-'I
ADDRESS
SEPTIC TANK,SEEP,PIT(S) � �
I HEREBY ACKNOWLEDGE THAT I HAVE READ THI APPLIC TION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAfDES
M THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
R�GATU
DE IN. THE ABCRIBED RESID N AL ERTV. ABANDON HOUSE SEWER
SRE BACKFILL SEPTIC TANKS ❑
PERMITTEE• ❑
, SEEP,PIT(S) ❑ CESSPOOLS
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
`L,Lc) 3 4 8 4`0 DEC 13 1 0 D 5.00- G.
YDEPA)Ei.TMZNT OF COUNTY ENGENEM I SEWER—SEWAGE DOSPOSAL
DIVISION OF BUILDING ARID SAFETY I PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIA!'y-$1g!''rfr1X. COUNTY ENGINEER BUILDING P
ADDRESS I O J ti
FOR APPLICANT TO FILL IN LOCALITY 'Coz
BUILDING NEAREST
ADDRESS 106 5 HA.I lwnnd Pro CROSS ST.
LOCALITY Temple City DISTRICT NO. SERIAL NO. p rPERMIT NO.
NEAREST � A � / J 2� 7S
CROSS ST. 7-1 Lim aAve o RECEIVED BY Ready for Inspection DATE ISSUED
r. OWNER PoL. IV1C NuttMAIL
ADDRESS 2721 San Gabriel Bl d o USE ZONE OCCUPANCY BK MAP PG
CITY San Gabriel TEL.NO- AT 94364
< CONTRACTOR L.D. & Mo Constr. Co. Cp 4�p=p_.p}8• �C �`7 3 E�.
ADDRESS 21 W. 'Nistarla Ave. V
JOB No. g-
CITY Arcadia TEL.NO. DO 62238 TRUNK PERMIT No.
STATE
REG[STRATION11bZ613 C 42 FICOUNTY ROAD PERMIT N0.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. 75 PERMIT NO.
BLOCK TRACT 19189 INDUSTRIAL
WASTEAPPROVAL
SIZE OF LOT N0.OF BLOGS.
NOW ON LOT `� CHARGES
BSOF
UE DINGS Res o & Garage CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE /
CONNECTING TO REIMBURSEMENT FEE
HOUSE—SEWER
PUBLICSEWER @ $ 3.50 _3 soRECEIPT NO. I DATE BY
HOUSE SEWER CONNECTING TO !1
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDB.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO I DAf E 18Y
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 .'��� Q DEPTH V _
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 /ea
i 1}tANUHOLE PPER REFERENCE
T
TYPE OF CONNECTION LENGTH FROM /
OWNERS PERMIT $ 1 00 Y. CU" P-L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE 4 50
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
SIGNED THIS......._...........DAY OF...........:___--........_.......19----- NEW HOUSE SEWER S p G 'I
OWNER OR CONNECT ADDITIONAL _
OWNERS AGENT.......................................... -•---. BUILDING OR WORK
------_- SEPTIC TANK,SEEP.PIT(S)
ADDRESS--------- `
----------------__--•-------•--------------------------- AND/OR DRAINFIELD
I HEREBY ACKNOWLEbGE THAT 1 HAVE READ THIS APPLI- CESSPOOL[j 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS E]
SEEP.PIT(S)E:] CESSPOOLS I]
SIGNATURETD
yQ x
OF PERMITTEE.--11oo-.CC-.. p- o GOa••------•-
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