HomeMy Public PortalAbout5044 PERSIMMON AVE_Sewer__ DEPA1{iMENT 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 LOCALITY
BUILDING NEAREST
ADDRESS 50" Pe r—g i tTiTrlE';;=Et VP4 CROSS ST.
LOCALITY E1 korate DISTRICT NO. SERIAL NO. PERMIT NO.
CROSS ST. Grand Ave* & Freer Ste
A S
`RECEIVED BY Ready for Inspection DATE ISSUED
OWNER pals• MONUtt
MAIL
ADDRESS 27Z SAn Gabriel Blvde USE ZONE I OCCUPANCY BK MAP PG
CITY San GabrielTEL.NO. T 3 I I
CONTRACTORT,`-p+ & • (1011STIICTION 00, CO.IMP.NO.
ADDRESS 408 `Vintbr®p Drr
JOB aa.
CITY TEL.NO. -AT 48315 TRUNK PERMIT NO.
113613 G 42 STATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. J;B STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT 17867 INDUSTRIAL
SIZE OF LOT NO.OF BLDGS. WASTE APPROVAL
c�y
NOW ON LOT L CHARGES
USE OF
BUILDINGS 1 ReS. CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER @ ; 3.58 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- DATEI 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 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT ; 1 00 Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION I 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 ( 4
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT---..----------......................................................_......... _BUILDING OR WORK
_-.------_.-_.. SEPTIC TANK,SEEP.PIT(S)
ADDRESS----.
--------•----------•-------••--------------•-------•------•----------- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL 0 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
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND
DISCONNECT ABANDON NOPLUG PLUGAND
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS I]
SIGNATURE SEEP.PIT(S)o CESSPOOLS
OF PERMITTEE-` ------- ------ ------ ----.......
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