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DEPARY'MENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 7
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION 1
COUNTY OF LOS ANGELES n
WILLIAM J. FOX, COUNTY ENGINEER I pOORE1 NG SS 1// lIJ S r
l� FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST
ADDRESS 10703 Ta RORJ4 Rt. CROSS ST.
LOCALITY El Monte DISTRICT
��NO. SERIAL NO. PERMIT NO.
NEAREST �J^�y A 'y� .533.5=$,I,?5
GROSS ST. F.l M11tA Ave. RECEIV ,O®BY Ready for lnapeetipp DATEISSUED
OWNERMAIL
P L MriQl]ta_t ,, E�
ADDRESS 272.2 San Gabriel Blvd. USpZONE OCCUPANCY I RK MAP PG
CITY San Gabriel TEL.NO. T dp�
CONTRACTOR D. & Me Construotion Co. - _,",_....�--
00.IMP.N0.
ADDRESS 406 Winthrop Bit.
JOB N0.
CITY Alhambra TEL.NO. AT 48315
TRUNK PERMIT N0.
REGISTRATION NO. 11'3(1'3/' C 42 COUNTY
ROAD PERMIT N0.
LEGL
DESCRIPTION LOT NO. ¢q STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT 17867 WASTE APPROVAL\
SIZE OF LOT N0.OF BL
NOW ON LOT OT
2 CHARGES \
USE OF 1 Rest
BUILDINGS CONNECTION CHARGE FEE1 i./
NO. DESCRIPTION OF WORK FEE 11
HOUSE SEWER CONNECTING TO R E!MSURSEMENTFEE r
1 PUBLIC SEWER (jp S 3.50 RECEIPTFNO. ND TE `I BY \
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDO.OR EXCEPTION RECORDED \
WORK TO HOUSE SEWER 1.00
ALTERORREAAlR EXISTING ND' I `OATE� � BY a
SEWER OR DISPO SAL SYSTEM I.60
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR u D
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH A
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 ' (j / WdS;IN EFERW,7q
w/F',,cTrL
6R
TYPE OF CONNECTION LENGT,H,SR
OWNERS PERMIT $ 1 00 Y, GURB` P.L. 4W!L!.TO P.L.
AUTHORIZATION I 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
SIGNED THIS--------------------DAY OF.._... ----------------------_.._...19.._._ NEW HOUSE SEWER -l7o
OWNER OR - CONNECT ADDITIONAL
OWNERS AGENT------------------........._........_._.._....................._...._........_ BUILDING OR WORK
ADDRESS.......----- __.
__........._. SEPTIC TANK,SEEP.PIT(S)
_......_.._..__....._........._......._._._.._..._. AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL E] 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 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN. ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE ��//����//JJ ••/��/��7!7//n' �_ ' / SEEP.PIT(S)Q CESSPOOLS
. OF PERMITTEE_1S!_/_•...._...... ._LG.r��•�LYE'�!'1..._.._.
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