HomeMy Public PortalAbout5422 BALDWIN AVE_Sewer__ (2) CITY OF TMPLE CITY
E808 D
CAPPLICATION FOR PERMIT'
eeoe a so COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 7ADDRESS
422 BaldwinAve.
JOHN A LAMBIE County Ea eer CAssATf D GRIFFIN Supt of Buildiagemple City
FOR APPLICANT TO F Il IN liveLEGAL rray an a verson
DESCRIPTION LOT 0 OWNER
BLOCKlryrcfla— MAIL
ADDRESS 535 190. Second Street
NO OF BLDGSovines ED
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS Res* DIST�NOGROUPI BK MAP PG PROCESS qY
CONTRACTOR • • & w• OnS r• O•
ADDRESS 5136 No. Bleecker St. CONNECTION PMAT
CITY Baldwin Park TEL NO ED 8-3024' STATION DEPTH
REGISTRATION NO 113613 STATE MANHOLE REFERENCE / UPPER
COUNTY / LOWER
No I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO C
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L To P L
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 C
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1 00
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1 00 PERMI
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PERMIT f 2 00 CONNEC CHARGE FEE
AUTHORIZATION TOTAL FEE 6� REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER /J �
SIGNED THIS DAY OF 19- NEW HOUSE SEWEROWNER OR
OWNERS AGENT�� CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
LHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
STATE THAT THE ABOVE IS CORRECT AND AGREE To COMPLY CESSPOOL ❑ DRYWELL ❑
ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
MBING AND SEWERS SEWAGE DISPOSAL SYSTEM
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
NSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
FORNIA OR THAT I AM T LEGAL OWNER OF THE ABOVE
RIBED RESIDEN L PRO T BACKFILL SEPTIC TANKS ❑
ATURE
SEEP PIT(s) ❑ CESSPOOLS ❑
PERMITTE
OF ALIDATION ROBERT A WOOD
CK H o CASH SUPERVISING MECHANICAL ENGINEER
L�Ca 8 6 7 0 -0 AoV 18 1 0 a 500 '9