HomeMy Public PortalAbout5214 PERSIMMON AVE_Sewer__ DEPAIVrTUENT 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
ADDRESS 5214 Pers3mou kye• NEAREST
CROSS ST.
LOCALITY El konte DISTRICT NO. SERIAL NO. PERMIT NO.NEAREST
c
CROSS ST. Grand gye• & Freer St+• A J
OWNER PIL• 11110NUtti RECEIVED BY Ready for Inspection DATE ISSUED
MAIL OCCUPANCY{
ADDRESS P-721P-721� �� San Gabriel Blvd. USE ZONE I I BK MAPPG
CITY San Gabriel TELAO.Lt 96364
CONTRACTOR T,• o �� r� 7OIO00*
CO.IMP.NO.
ADDRESS 408 Winthrop Dr.
10B N0.
CITY ai�.�7ambra TEL.NO. � 48315
TRUNK PERMIT NO.
STATE
REGISTRATION NO. 11361u G 42 COUNTY
ROAD PERMIT NO. -
LEGAL
DESCRIPTION LOT NO. 79 STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT 17667 INDUSTRIAL
SIZE OF LOT - N0.OF BLDGS. WASTE APPROVAL
�
NOW ON LOT w CHARGES
USE OF
BUILDINGS l 'R6$s CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
1 PUBLIC SEWER 0 $ 3.50 RECEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO i
PRfVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
_ WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING ND. i DATE (BY
SEWER OR DISPOSAL SYSTEM 1.00 4
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 I 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 APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
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[-] DRYWELL
CATIONAND 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 IAM 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
SIGNATURE SEEP.PIT(S)0 CESSPOOLS
OF PERWTTEE. .- - -"
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