HomeMy Public PortalAbout5119 BALDWIN AVE_Sewer__ (2) 642D 2/70
76A APPLICATIO FOR PERMIT
76A 6
COUNTY OF LOS ANGELES SEWER-SE GE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION [LOCALITY
ILDING
JOHN A. LAMBIE. COUNTY ENGINEER DRESS d
COLEMAN W. JENKINS. SUPT. OF BUILDING
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
(PRINT OR TYPE ONLY)
DLEAL
ESCRIPTION LOT NO. OWNER �• /�4'� EY y M.r�
MAIL
BLOCK TRACT ADDRESS
/ NO. OF BLDGS.
SIZE OF LOT 77 V NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP CLASS MAP n'PG SSED BY
® �. .! 9/ S/Ls
CONTRACTOR Q
ADDRESS 9� CONNECTION DATA
CITYef�b TEL. NO. ILS STATION 2--W-) DEPTH
STATE LIC MANHOLE REFERENCE � -
LICENSE NO. GLASS V I ZD LOWER
NO. .DESC IP ON OF WORK FEE YPE OFC TION LENGTH FROM
HOUSE SEWER CONNECTING TO + fl /' CURB P.L. M.L.TO P.L. 16
PUBLIC SEWER .00 S/ lV
SEPTIC'TANK.SEEPAGE PIT OR �/ P.C.NO.
PITS AND/OR DRAINFIELD @ SIO.00 CO.IMP. NO. ,: JOB NO. �./
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. IA.
PRIVATE DISPOSAL SYSTEM @ 'S3.00 3
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVED I EASEMENT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ 83.00 V
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL.MAN HOLE @ S5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING O
SEWER OR DISPOSAL SYSTEM 83.00 STATE ENCROACHMENT (f
PERMIT NO. Lu
INDUSTRIAL En
WASTE APPROVAL
OWNER'S PERMIT $ 3 00 CHARGES
AUTHORIZATION1 TOTAL FEE L l0 CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY F 19_ �
OWNER OR1p /rb/v�Ry NEW HOUSE SEWER
OWNERS AGENT— ��"ff/dd _CC %ysI/YA_/ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL Cl DRYWELL ❑
I HEREBY CERTIFY THAT A PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED L ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT T LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB RIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE - - -
OF PERMITTEE BACKFILL SEPTIC"T.A' K-§lt(]'
SE-EP.-PPTSBr--Q CESSPOOLS
VALIDATION JACK R. ALLEN
CK� M.0. CASH SUPERVISING MECHANICAL ENGINEER
COUNTY OF LOS ANGELES - TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SE 0508 0706110001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: ISEWER / SEPTIC: SEWER BUILDING ADDRESS:
1TR: 9481 (EXIST OCC GRP: 5119 BALDWIN AV
I 1BLDGS. NOW ON LOT: TEMP CA 917803902
(ASSESSOR INFORMATION NUMBER: lCONNECTION TYPE: NEAREST CROSS STREET: LA ROSA
18589-007-002 ORIGINATION: THOMAS PAGE: 597 GRID: B4 LOCALITY: TEMPLE CITY, Cl
I ILENGTH ML TO PL: STATION: DEPTH:
(TENANT: IMANHOLE REFERENCE: UPPER/LOWER: JISSUED ON: PROCESSED BY: EXPIRES ON:
1 106/11/07 SR 12/08/07
ICOUNTY IMPROVEMENT NUMBER:
(OWNER: TEL. NO: 1PLAN CHECK NUMBER: F NAL DA FI AL BY: CODE:
IMATTA RON R;GEORGIA A (626) 443-5721- 1JOB NUMBER:
I
15119 BALDWIN AV 1TRUNK PERMIT NUMBER: I
ITEMP 917803902 IROAD PERMIT NUMBER: IDES�ION OF WORK I
1
I IAFFADAVIT: NO ICONNECT 2ND UNIT TO PUBLIC SEWER 1
1 (WAIVER: NO 1 1
(APPLICANT: TEL. NO: (EASEMENT: NO I
IMATTA (626) 826-8391- I
15119 BALDWIN AVE. 1RECORD INSTRUMENT NBR: RECORD DATE: ISPECIAL CONDITIONS: 1
ITEMPLE CITY CA 91780 1HIGHWAY/STREET WIDENING:
I ISTATE ENCROACHMENT PERMIT NUMBER: 1 1
I I I I
ICONTRACTOR: TEL. NO: I FEES PAID - 1APPROVALS DATE INSPECTOR SIGNATURE 1
IMATTA, RON (626) 443-5721- 1 1 1
15119 BALDWIN AVENUE LIC. NO 1FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: INEW HOUSE SEWER 1
ITEMPLE CITY, CA 91780 NONE 1 1 ! 1 1
1 101 PERMIT ISSUANCE FEE 27.75 ICONNECT ADDITIONAL 1 I
1 103 CONN TO PUBLIC SEWER 1.00 CON 46.95 1BUILDING OR WORK I I I
(ARCHITECT OR'ENGINEER: TEL. NO: I TOTAL FEES 74.70 1 1 I I
1 - I 1SEPTIC TANK, SEEPAGE PITI I I
1 LIC. NO: I 1AND/OR DRAIN FIELD 1 I I
I I I I I I
1 1DRYWELL _ 1
I I I I I I
SEWER MAP BOOK: PAGE: (ALTER, REPAIR, SEWER OR I I I
SEWAGE DISPOSAL SYSTEM 1 I
I I I I I I
1 1 1DISCONNECT PLUG AND 1 I I
I I 1ABANDON HOUSE SEWER I I I
I I I I I I
1 I IBACKFILL SEPTIC TANKS
1 1 (SEEP. PIT _ CESSPOOL
I I I I I I
I 1GRAYWATER SYSTEM
I I I
I I I I I I
I I I I I I
I I I I I I
I I I I I I
I I I I I I
I I I I I I
I I I I I I
1 IREPORT ID: DPR266 ROUTE TO BS0508
I I I I I I