HomeMy Public PortalAbout5038 PERSIMMON AVE_Sewer__ DEPAI 17MENT 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 PILL IN LOCALITY
BUILDINGNEAREST
ADDRESS [)3
j3 �rara9rrsrst?213 A:Ve CROSS ST.
LOCALITY � U 1lie DISTRICT NO. SERIAL NO. PERMIT NO. C
CROSS ST. Grand Ave r & Freer Sts NEAREST
� J
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER P-L-MAIL
l e'N21tt
ADDRESS 272-- San Gabriel Blvd USE ZONE I OCCUPANCY MAP
CITY San Gabrie TEL.NO. AT 94$64 � I BK PG
CONTRACTOR T—1) g-- X. C .11TUT-701101 �'Cr CO.IMP.N0.
ADDRESS 4C8' _nthrab Dre JOB NO.
CITY Alhambra TEL.NO. AT 48315TRUNK PERMIT N0.
STATE
REGISTRATION NO._ 1..1°3�i�3 C Al2 COUNTY ROAD PERMIT N0.
LEGAL
DESCRIPTION LOT NO. �ry STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT � �(37 INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS.
_ NOW ON LOT CHARGES
USE OF
BUILDINGS 1 (ggr CONNECTION CHARGE FEE
NO.I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
_ PUBLICSEWER @ $ 3.50 RECEIPT NO. DATE BY
NOUSE SSEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- I 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
ITS AND/OR GRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT r o0
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
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
SEPTIC TANK,SEEP.PITS)
ADDRESS -- _._.. - ---------------- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELL I]
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
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)E] CESSPOOLS
SIGNATURE
OF PERMITTEE---- - -------------------•--------------------- ....
76A642D 663 1/53