HomeMy Public PortalAbout4820 BALDWIN AVE_Sewer__ (2) 76A f420�- CE808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDIN
ADDRESS T1 a�G !I t82 Q20 N. Baldwin Ave•
LOCALITY Temple Cit
NEAREST Lower Azusa Ed.
FC,TYE1
OR APPLICANT TO FILL IN cRosB ST
Richard Bowen
ION LOT NO OWNER
MAIL 1 20 Melanie Ln.
TRACT ADDRESS �1y[
NO OF BLOT6 Arcadia TEL NO 445-1197
LOT NOW ON LOT CITY
Des• DISTRICT NO GROUP MAP PROCES D BY
S 11
TOR Square Deal Sewer Service
1`K
2933 Maxson Rd. CONNECTION DATA
l Monte TEL NO STATION J ' DEPTH
444 eu?.o
STATE LIC
1
LICENSE NO 128870 CLASS C-42 MANN REFE E U v LOWER
NO DESCRIPTION OF WORK FEE ' TYPE OF CONNECTION LENGTH FROM
1 PHOUSE SEWER UBLIC SEWER_CONNECTING TO $7 00 �1 �1oo Y CURB P M L TO P L
SEPTIC TANK SEEPAGE PIT OR •l 1 p P C NO
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO / JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM $3 00 TRUNK PERMIT NO ROAD PERMIT N6
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVI■I IALIIIIMT RECORD INSTR NO DATE
WORK TO HOUSE SEWER ® $300
OVERFLOW SEEPAGE PIT DRAINFIELD V
EXTN CESSPOOL DRYWELL @ $5 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM $300
STATE ENCROACHMENT (--
MANHOLE $T 00 PERMIT NO W
0 INDUSTRIAL N
WASTE APPROVAL �
CHARGES —
OWNER'S
PERM a
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FE /
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR T0C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLISEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTICTANK SEEP PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFIA OR THAT 1 AM THE LEGAL OWN OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESIDE IAL ROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PER MTTTEE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION CK M 0 CASH
2-4 6 MAR 21 1 a B 1 15.0 0 AS--