HomeMy Public PortalAbout5022 BALDWIN AVE_Sewer__ (2) 76A 6420 -CE808 -10 71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 5022 N Balawln Ave.
ADDRESS
LOCALITY Temple City
FOR APPLICANT TO FILL IN NEAREST Lower Azusa Fad.
CROSS ST
AL
[F'SGPTION LOT NO OWNER Albert Wirz
` MAIL 5022 Id Baldwin Ave.
TRACT / ADDRESS /Y
OF LOT NOWOON LOTS CITY Temple CityTEL NO
F pINGS Fie s. DISTRICTNO GROUP MAP EED 8Y
'� BK pACTOR S uare Deal Sewer Service �d6 / ,f -_4,-SS 2 Maxson Rdl'-t.'-I _/ CONNECTION DATA
E1 M0nSTATEQteQ TEL NO "f'�A'I'�2020 STATION /.� DEPTH
LI
CENSE NO �2HH7O GLALIC SS C-�2 MANHOLE REFERENCE/Gµ/ `3*/Or7 `�1 � LOWER
DESCRIPTION OF WORK FEE TYPE OF CO�I�IEGTI(OJNJ LENGTH FROM
HOUSE SEWER CONNECTING TO Y URBP L M L TOP L
PUBLIC SEWER 0 $7 00 00SEPTIC TANK SEEPAGE PIT OR � P C NO
PITS AND/OR DRAINFIELD @ 51000 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO G ^ aPRIVATE DISPOSAL SYSTEM 5300 a OCONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATEWORK TO HOUSE SEWER @ S300OVERFLOW SEEPAGE PIT DRAINFIELDEXTN CESSPOOL DRYWELL @ 5300HWV OR ST WIDENING OALTER REPAIR OR ABANDON HOUSE HSEWER OR DISPOSAL SYSTEM S300 STATE ENCROACHMENT WMANHOLE 0 $7 00 PERMIT NO INDUSTRIALWASTE A Z
CHARGESOWNERS PERMIT S s o0HORIZATION TOTAL F'EE 10 00CONN TIEF a,lin_ TOW PF
REIMB RS aVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON � 'TOR TO COVNECT THE ABOVE DESCRIBED EXISTINGDWELLINGHE PUBLIC SEWER PPROVALS DATE IV
CTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HO E SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
I 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWN4R OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE D SCRIBED RESIDE IA ROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILLSEPTI AN S I
OF PERMTTTE SEEP PIT S) CESSPOO"LS �/A�
/� o
VALIDATION OK M 0 CASH
✓'-Ir U 3 dC'-MAR 3 1 3 0