HomeMy Public PortalAbout10726 LA ROSA DR_Sewer__ OEPAXrMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS.ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I ADDuit-RESS w <<0 Ad Jia s L- 5
FOR APPLICANT TO FILL IN LOCALITY
ADDRESS NEART
10726 La Rosa St V' CROSSEST. -r--
i
LOCALITY R-.Z MD*+tP $. DISTRICT NOO..J SERIAL NO. PERMIT NO.
CRROSSSTA
. El Monte Ave. ' �v �7✓y S'3� -°� S
RECEIVED/BY Ready fee Inspection DATEISSUED
OWNER P . T MPTTntt I �f'Y 7� �
MAIL
ADDRESS U San Gabriel Blvd. USEZONE OCCUPANCY MAP
CITY San Gabriel TEL.NO:.AT 4364 B=_ PG
CONTRACTORL D & M_
(`OWgTRTTCIPTOA CO. CO.IMP.N0:
ADDRESS Ana `TJimthrrp Dr. IDB No.
CITY Alhambra TEL.No. AT 46315
TRUNK PERMIT N0.
STATE
REGISTRATION NO. 113613 C 42 ENOUNTY�
ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO.
BLOCK TRACT 17667 INDUSTRIAL',
NO.OF BLDGS. WASTE APPROVAL
512E OF LOT NOW ON LOT
1 ��, CHARGES
USE OF
BUILDINGS 1 Rea. CONNECTION CHARGE FEE_
NO. DESCRIPTION OF WORK FEE F ,/
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
1 PUBLIC SEWER 0 S 3.50 RECEIPT NO. I DATE I BY
H OUSE SEWER CONNECTING TO (
PRIVATE DISPOSAL SYSTEM Lm
CONNECT ADDITIONAL BLDG.OR .EXCEPTION RECORDED.
WORK TO.HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- DATE 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 GRAINFIELD 2.00 �- .STATION 2G? DEPTH In � -
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 &'s-W ��pNU PeRREFEREN 4-1— LOWER
T PEOFCONNECTI ON LENGTILEROM
OWNERS PERMIT ; 1 00 Y. CURB` P.L. V .M'L:TO P.L.
AUTHORIZATION 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 �' 0 --�
OWNER OR. CONNECT ADDITIONAL
rr . OWNERS AGENT-.........._......_.._.._._.....__.._......_.-_. - BUILDINGORWORK
ADDRESS-----------_---......_. ------.-----.--._.L SEPTIC TANK,SEEP.PIT(S)
.._.._......_.........-----------------.. - ANO/OR GRAINFIELD
'THEREBY-ACKNOWLEDGE THAT.1 HAVE READ THIS APPLI-' :CESSPOOL[] DRYWELL D
'CATIOWAND STATE THAT THE ABOVE IS CORRECT AND'AGREE
-TO.COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS1 ALTER.REPAIR,SEWER OR
REGULATING PLUMBING'AND SEWERS. 'SEWAGE DISPOSAL SYSTEM
IHEREBY (CERTIFY THAT 1 AM PROPERLY REGISTERED. DISCONNECT PLUG AND
AND/OR LICENSED'AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE PLUG AND
AND-STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL.OWN.
SI OF THE ABOVESCRIBED RESP PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE // SEEP:PIT(5)0 CESSPOOLS
OF PERMITTEE.
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