HomeMy Public PortalAbout6103 HART AVE_Sewer__ 76A 642D - CE808 - 9/73 APIf-LL CATOON FOR PERMOT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL_
-DEPARTMENT OF COUNTY ENGINEER 1
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS 6yO3 NO Hart Avec
LOCALITY Temple City
NEAREST
FOR APPLICANT TO FILL IN CROs ST.
LEGAL +�
DESCRIPTION LOT NO. �I-i� /L �. OWNER Rosemead nStYUCt• n
MAIL
BLOCK TRACT S C�lig ADDRESS 527 Sc Atlantic
NO. OF BLDGS. 7��
SIZE OF LOT NOW ON LOT CITYl`j011tere Park TEL. NO. 443-9513
USE OF DISTRICT NO. GROUP MAP PROCESSED 8Y
BUILDINGS BK PG
GONTRACTOFnwenBms. PlumbingJ�O V +�' ,(/- 7
ADDRESS 65 N* Baldwin Ave* /� CONNECTION DATA
CITY El Monte TEL. NO. LLli3-OO(O�J�} STATION DEPTH
STATE 231 741 LIC C 0 MANHOLE REFERENCE - UPPER
LICENSE NO: CLASS LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER '0 $7.00
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO.
E W
HOUSSEER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3 00
CONNECT ADDITIONAL BLDG.OR %y q6-0, r AFFIDAVIT WAIVE. [Al.W RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER ®
d
OVERFLOW SEEPAGE PIT.DRAINFIELD O
EXT N..CESSPOOL.DRYW ELL. Q $5.00 C.7
ALTER.REPAIR OR ABANDON HOUSE
HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM Q $3.00 STATE ENCROACHMENT
MANHOLE $7.00 PERMIT NO. W
INDUSTRIAL
a-
WASTE APPROVAL 0*3
CHARGES
OVVNER'S PERMIT 8
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE D()
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING p
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT
AL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(5)
I HEREBY ACKNOWLEDGE-THAT I HAVE READ THIS APPLICATION 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 ❑ -
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REOUI ED BY LO ANGLES NTY D STATE OF SEWAGE DISPOSAL SYSTEM
CCALI FCRN IA OR TH I AM T GAL OW E OF INTEND
TO DISCONNECT PLUG AND
RESIDE IN.'THE A E ES I ()RESIDE TI L O ERTY I ABANDON HOUSE SEWER
SIGNATURE -/ a / ❑
OF PEQMTTTEE [� G�/ T .r�./ BACKFILL SEPTIC TANKS
�yR yp�R ySyEEPp.*PIT fS) ❑ CESSPOOLS ❑
tl ALIbATIOlV CK., M.O. CASH
9.0 U a`:
C g3 �� : �
DEPAJU MENT 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 OCALITY
BUILDING NEAREST
ADDRESS CROSSST.
LOCALITY D!STRiCT NO. SERIAL NO. PERMIT NO.
NEAREST - A S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL USE ZONE OCCUPANCY MAP
ADDRESS _ I BK PG
CITY TEL.NO.
CONTRACTOR
CO.IMP.NO.
ADDRESS
JOB NO.
CITY TEL.NO. TRUNK PERMIT NO.
❑ STATE
REGISTRATION NO. ❑ COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE Of LOT NO.OF BLDGS.
NOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLICSEWER @ S 3.50 RECEIPT NO. DATE IBY
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- 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
CESSPOOL—DRYWELL STATION DEPTH
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ I 00 Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION 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---------•-------------•-----------•---•---------------I--- BUILDING O R W O RK
.................................................._---_ SEPTIC TANK,SEEP.PIT(S)
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 DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT i AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PIT(S)❑ CESSPOOLS I]
OF PERMITTEE---------------_...................... ---- ---------
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