HomeMy Public PortalAbout5114 PERSIMMON AVE_Sewer__ DEPAWMENT 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 5114 Perig1 n?i Aypa CROSS ST.
LOCALITY El M011te DISTRICT NO. SERIAL NO. PERMIT NO.
NEARESTA S
CROSS ST. rArd Ave. Qr Pre _r St, ——
RECEIVED RY Ready for Inspection DATE ISSUED
OWNER --C•�+i12� C
MAIL
ADDRESS `J'rZ,J San Gabriel Blvd. USE ZONE OCCUPANCY BK MAP PG
CITY San Gabriel TEL-NO. At 94369
CONTRACTOR LQ, & M1, GMSTRUOTION 00, CO.IMP.NO,
ADDRESS m408 Winthrop DTs
JOB NO.
CITY Alhambra TEL.NO.AT 4$31: TRUNK PERMIT NO.
STATE
REGISTRATION NO. 113613 C 42 19 COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. !1 STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT 17867 INDUSTRIAL
SIZE OF LOT N0.8F BLDGS.
WASTE APPROVAL
NOW ON LOT "?4 CHARGES
USE OF
BUILDINGS 1 R65. CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
1 HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER_ @ $ 3.50 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
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/ORDRAINFIELD 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 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.PIT(S)
ADDRESS...
..........-......--_•----- _......----•----•-----••-•-• AND/OR DRAINFIELD
! HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLI- CESSPOOL[] 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 REGISTE... 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
SIGNATURE SEEP.P[T(S)E] CESSPOOLS I]
OF PERMITTEE----------...... --...............__-----------... - e..._..
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