HomeMy Public PortalAbout5428 BALDWIN AVE_Sewer__ (2) ' C I T Y p F T E M P L E C I T Y
A842D
CE808 8 88 APPLICATION FOR PERMIT
CE
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
- DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 5428 Baldwin Ave.
ADDRESS
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O AMA LAMBIE CountF En e.r
C AY1 D GIUTM Supt of Build q LOCALITY Temple its
NEAREST
FOR APPLICANT TO FILL IN CROSS ST Olive
LEGAL - � + d Q C b
DESCRIPTI OT 0 .'a ; OWNER
BLOCK a� `� c r� MAIL 535 So. Second Street
t ADDRESS
NO OF BLDGSED 14889
SIZE OF LOT NOW ON LOT CITY Covina TEL NO
USE DI DISTRICT NO GROU MAP PROCESSED BY
BUILDINGS B �ta BK PG
�r� r
CONTRACTOR • • M. O ,J t r• CO. S 0 t
ADDRESS 5136 No. Ble a cker St. CONNECTIo DAT
CITY Baldwin ParkEL NO ED 8-3024 STATION DEPTH
ll 6l STATE MANHOLE REFERENCE. UPPER
REGISTRATION NO 3 3 COUNTY
No I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
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 0
PRIVATE DISPOSAL SYSTEM @ $1 00 � � -108-NO
CONNECT ADDITIONAL BLDG OR TRUNK P NO ROAD PERMI
WORK TO HOUSE SEWER @ $1 00
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHME
SEWER OR DISPOSAL SYSTEM @ $100 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PERNUT $ 2 00 CONNECTI CHARGE FEE r
AUTHORIZATION TOTAL FEE ( REIM URSEMENT 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 ,I
SIGNED THIS DAY OF 19_ NPW HOUSE SEWER A /(n 4OWNER OR
OWNERS AGENT CONNECT ADDITIONAL
NEW BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM TH EGAL OWNER OF HE ABOVE
DESCRIBED RESIDENTI ROP J BACKFILL SEPTIC TANKS ❑
/
SIGNATURE SEEP PIT(S) [ICESSPOOLS ❑
1L�
OF PERM ITTE
®' VALIDATION ROBERT A WOOD
CK m 0 CASH SUPERVISING MECHANICAL ENGINEER
LJIU g 8 NOV 1 g ; o D 5 C
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