HomeMy Public PortalAbout5032 PERSIMMON AVE_Sewer__ _ 1
76A 8'42,4r'CE ae A-7176 APPLICATION FOR. PERMIT'
SEWER—S.E`+NAG,t. DI.SPOSA`L
'COUNTY OF.LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BU.I:LDING'AND. SAFETY DIVISION
DISTRICT NO.. GROUP MAP PRO EBBED BY
FOR APPLICANT TO FILL IN BK. PG
'BUlLO1NG `�.g 05" 0z '.
t7/
CONNECTIONDATA-
LOCALITY
NEAREST STATION DEPTH
CROSS .ST. �.j^ _ _ UPPER'
MANHOLE REFERENCE LOWER
OWNER _ TYPEOF CONNECTION LENGTH-:FROM`
MAIL Y, CURB _ P.L. M.L.TO P.L.
ADDRESS 01 Al h _ __ P.C.NO..
CITY �"_ 1�1 TEL. NO. CO.IMP.NO: Job NO..
LEGAL /�. 'TRUNK PERAIIT.NO.. ROAD PERMIT NO.
DESCRIPTION LOT NO
_AFFIDAVIT' WAMS vAS[luNT' RECORD.INSTR,'NO. DATE
BLOCK TRACT ,
,^ NO. OF SLOGS.
SUE OF LOT �v ��� NOW'ON LOT � HWY.OR ST:..W.IDENING
USE OF
BUILDINGS Lo. es
STATE.ENCROAC100141T
J
PERIA.IT NO.
INDUSTRIAL
'CONTRACTOR - WASTE APPROVAL '
ADDRESS / _ CHARGES Q
CONNECTSON CHARGE FEE.
CITY TEL.'NO.
,'r. •��r�.O _ '%" - OC'
.STATE LIC .REtWOURSEMENT FEE 0
LICENSE" NO, ' GLASS .. .
'NO. DESCRIPTION OF WORK FEE APPROVALS DATE I,NSPECTOWS SIGNATURE yVj
HOUSE•SEWER.CONNECTING TO
PUBLIC SEWER Q' NEW HOUSE SEWER z
SEPTIC LANK.-SEEPAGE.PIT OR - -
PITS ANGOR DRAINFIELD CONNECT ADD OL
HOUSE SEINER CONNECTING-TOBUIL'DI NG O ORK �'�- � >�}'1•e�
PRIVATE-DISPOSAL.-SYSTEM. SEPTIC TANK:SEEP,PIT(5) ,
CONNECT ADDITIONAL BLDG:ORAND/OffDRAINFIELD
WORK TO HOUSE,SEWER
''OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ❑ DR-YW.ELL [3 '
:EXTN:.CESSPOOL.DRYWELL.MANHOLE
ALTER.REPAIR OR•AlBANOON HOUSE ALT,ER;,6REPAIR•SEWER OR
SEWER OR DISPOSAL SYSTEM Q SEWAGE DISPOSAL.SYSTq-M
DlSCON.NECT PLUG AND '
ABANDON HOUSE SEWER.
6ACKFILL SEPTIC TANKS ❑
_ SEEP.PIT IS) :❑ CESSPOOLS ❑
OWNER'S • Issuance:Fee S. .' .
AUTHORIZATION TOTAL FEE ; .Ad. I HEREBY,AcKN.OWLEDGE THAT I HAVE READ THIS APPLICATION
4xV AND 'STATE THAT THE ABOVE. IS CORRECT AND AGREE'TO''COMPLY
WITH -ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
1-'HAVE AT THIS DATE:A CONTRACT WITH THE HEREIN NAMED CON+• PLUMBING AND,SEWERS.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING j HEREBY -CERTIFY THAT.I AM PROPERLY REGISTERED AND/OR.
70 THE 'PUBLIC SEWER. LICENSED AS REOU.1.0 BY L09 ANGLES COUNTY-AND STATE*OF
SIGN-ED.'T,HISD Y CF 19_. CALIFORNIA OR THAT."1 AM THE LEGALWWNER OF..AND' INTEND TO
OWNER OR• RESIDE' IN; THEA BOVE"DES ED'RESIDENTIAL PROPERTY,'
OWNERS AGENT
S'IGN ATURE
00
OF' PERMTTTEE - -
. AIIDA�TIO'
0. GASNWORKERS moOVPclaPTYOM _
1
'POLICY HOLDER.�
DEPAItrMENT OF COUNT' 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 LOCALITY
BUILDING NEAREST
ADDRESS 5032 Persimmons Ave. CROSS ST.
LOCALITY DISTRICT N0. SERIAL NO. PERMIT N0.
NEAREST
ROSS ST. Grand Ave, & Freer St, A S
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER Pa s• McNutt
MAIL
ADDRESS 272,J San. Gabriel Blvd. USE ZONE OCCUPANCY MAP
BK PG
CITY San Gabr!el TEL.NO. dT 94364
CONTRACTOR T+T)_ + 'Tng ( 0. CO.IMP.N0.
ADDRESS 486 ima-t op Iwo JOB NO.
CITY Alhambra TEL.NQit 46315 TRUNK PERMIT NO.
REGISTRATION N0. STATE
COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT 17667 INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF Bt S.
NOW ON L I CHARGES
USE OF
BUILDINGS I Res W CONNECTION CHARGE FEE
NO. DESCRIPTION OF WDRK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER @ $ 9.50 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
ALTER OR REPAIR EXISTING NO- DATE I BY
oEWER 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 DEPTH
CESSPOOL—DRYW E LL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LC',".€R
*TYPE OF CONNECTIONLENGTH FROM
OWNERS PERMIT $ I Dd Y. CURB P.L. M.L.TO PRL.
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS....................DAY OF................... 19..._... NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT......................................_.._.......... •-....._. BUILDING OR WORK
ADDRESS__------------* -_...------- .. SEPTIC TANK,SEEP.PIT(S)
_ AND/ORDRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE 1S 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 1 AM THE LEGAL OWN- _
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS[]
SIGNATURE SEEP.PIT(S)E] CESSPOOLS 0
OF PERMITTEE-_.... .__.------- ...... ....._................
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