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DEPAI "ENT OF COUNTY ENGINEER SEVER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX. COUNTY ENGINEER I BUILDIDRENG
ADSS
FOR APPLICANT TO FILL IN LOCALITY Q_®
BUILDING NEAREST OI y
ADDRESS 10666 Ha.l,WO0d Dr. CROSS ST. i v I\ v
LOCALITY Ihemple- City DISTRICT NO. AA SERIAL NO. PERMIT NO. c
CNEAREST
ROSS ST. }tel Monte J� f1
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER. P. L. hTeNnt tMAIL
ADDRESS -97a-11, San Gabriel Blvd. USE ZONE OCCUPANCY BK MAP PG
CITY San Gabriel TEL.NO.Ato. 94364
CONTRACTOR L. D. & M. Constr. Co. O
ADDRESS 21 IN. Wistaria Ave, JOB NO.
CITY Ardadia TELAO. DO 62238 TRUNK PERMIT NO.
STATE
REGISTRATION NO. 113613 C 42 Id COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT N0. 58 STATE ENCROACHMENTPERMIT NO.
BLOCK TRAJ�189 INDUSTRIAL
APPROVAL
N
SIZE OF LOT N0.OF BL OW ON LOT
9 CHARGES
USOF
BUE DINGS Res. 7 Gara.ge
CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
1--HOUSE SEWER CONNECTING TO 3 50 REIMBURSEMENT FEE
PUBLICSEWER C $ 3.50 RECEIPT NO. /DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 I
ALTER OR REPAIR EXISTING N�f-_� 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/OR DRAINFIELD 2.00 STATION ' �i DEPTH /
CESSPOOL—DRYWELL
_SPECIAL CONDITIONS ONLY 2.00 / / MANHOLE REFERENCE
UPPER Levu
TYPE OF CONNECTION LENGTH FROM /
OWNERS PERMIT $ 1 00 -y- ew4B" P.L. 1--M.L.TO P.L. L O
AUTHORIZATION TOTAL FEE
41 50
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'SSIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS....................DAY OF....................-........ ........19-•_-_ NEW HOUSE SEWER 5C D C. 2 - 7"
OWNER OR 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 I] 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 DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SEEP.PIT(S)E3 CESSPOOLS❑
SIGNATURE LD�
-- BsCQ � OOF PERM ITTEE. -- .--------- - •----- ---5 .- _ . ...-..-•-.....
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