HomeMy Public PortalAbout5241 SANTA ANITA AVE_Sewer__ HDIW"FXTlV� of COUNTY ETGIngEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COW= OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY C ,
ADDRESS 5241 No Double Dr.
NEAREST
CROSS ST.
LOCALITY Temple City DISTRICT NO. SERIAL NO. I PERMIT NO. c
CROSS ST. Freer St s A . 1Ggcctr$
nw RECEIVED BY Ready for Inepeodan - 'DA'DE.ISSU D
OWNER Roy Budd Jr. f
1, p 5)�tcP l���n `� _3
MAIL
ADDRESS 241 No Double Dre USE ZONE OCCUPANCY BK MAP"'
4 r I G
CITY Temple Ci'(•,yrEL.NO. 9
I
CONTRACTORGr$,Y1(°ich Const. Coo I �� �
Ave, CO.IMP.N0.
ADDRESS 9137 E,,Ardendale AJOB.N0. --4 r
CITYSan Gabriel TEL.NO.ATl o 6-9206 TRUNK PERMIT NO.
REGISTRATION N0.C-42 130538 F STATE
COUNTY ROAD PERMIT N0.IN-'I R_ L},
LEGAL STATE ENCROACHMENT_
DESCRIPTION LOT NO. PERMIT NO. -
BLOCK TRACT 13363 INDUS APPWASTROVALNO.OF
SIZE OF LOT 65X180 NOW ON LOTS" l \ CHARGES
USE OF _
Res.
BUILDINGS �e$o CONNECTIDN CHARGE FEE
NO. DESCRIPTION OF WORK FEE HREIMBURSEMENT FEE.,
OUSE SEWER CONNECTING TO
1 PUBLIC SEWER df s a•s0 3 150 RECEIPT NO. I! DATE IBY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED'
WORK TO HOUSE SEWER 1.00 f--NO: I DATE I BY
ALTER OR REPAIR EXISTING _
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 a+30. q DEPTH
CESSPOOL-DRYWELL
_SPECIAL CONDITIONS ONLY 2.00 IMANHOLE REFERENCE
LOWE
LTYPE OF CD`.N.NECTION LENGTH FROM
«r: f CUR$ 'Rw; M.L.TO P.L. d
OWNERS PERMIT $ I IE500
AUTHORIZATION TOTAL PEE 4 `�"'�'
IHAVE THIS DATE CONTRACTED.WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS I NSPECTOR'S SIGNATURE DATE
DWELLING TO THE. PUBLIC SEWER
SIGNED THIS.. 19...._ AY OF. _ qlt- .. 19.5_3 NEW HOUSE SEWER
OWNER -� / /� / CONNECT ADDITIONAL
OWNERS AGENdM___._____d �f�i BUILDING OR WORK
/ SEPTIC TANK,SEEP.PIT(S)
ADDRESS...........
_._... ......._..........�.. ....................._. . AND/OR DRAINFIELD
1 HEREBY ACKNO-ALADQE THAT 1 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND
DISCONNECT PLUG .
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON NOPLUGAND
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
1` ' SEEP.PIT(S)[] CESSPOOLS�/ I �.O-7v
SIGNATURE t r
OF PERMITTEE...�.r.._-•--.._:_....;-:--... } -
°• . �.:.....:�-a 3_�._.!:_.._._.... if
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