HomeMy Public PortalAbout5603 HELEO AVE_Sewer__ JAPPLICATION FOR PERMIT 1
cE808-8.aaeoe-a , COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING 5603 heleo _-
ADDRESS
JOHN A. LAMBIE. County Engineer el 1p e 1 y
CASSATT D. GRIFFIN. Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN
CROSS ST. Broadway
-DESCRIPTION LOT NO. OWNER o� • itzgerald
BLOCK TRACT 25202 MAIL
ADDRESSNO.OF r][�
SIZE OF LOT NOW ON LOTS CITY CRJJ TEL.N0. ED 2–/ 725
USE OF
BUILDINGS TR p M. STRICT N0. GROUP BK MAP PG . }EBBED BY
CONTRACTOR L• • t):, M. onst
ADDRESS - O• ee erCONNECTION DATA �—
CITY Baldwin Park TEL. N0. ED STATETATION S'L-� f l . DEPTH ZREGISTRATION NO. ST MANHOLE REFERENCE /� PPERNo. DESCRIPTION OF WORK FEEGPUBLICS SEWERCONNECTING TO0 $5SEPTIC TANK, SEEPAGE PIT ORTYPE OF CONNECTION LENGTH FROMPITS AND/OR DRAINFIELD @ $5CURB P.L. M.L.TO P.L.OVERFLOW SEEPAGE PIT, DRAINFIELD
EIITN.,CESSPOOL,DRYWELL.MANHOLE N $2HOUSE SEWER CONNECTING TOP.C.NO.
PRIVATE DISPOSAL SYSTEM ® $1O.IMP.NO. OBNCONNECT ADDITIONAL BLDG.ORRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER Q $1ALTER, REPAIR OR ABANDON HOUSETATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM $1ERMIT NO.
IN
WASTE APPROVAL
CHARGES
OWNERS P +MMIT $ 2 0�0 ) CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE C U REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER -Iq- h ,
SIGNED THIS DAY OF 19_ATE
NEW
ADDITIONAL 1
OWNER OR T,T- BUILDING OR WORK
OWNERS AGENT tYy JUL
SEPTIC TANK,SEEP,PITS)
ADDRESS AND/OR GRAINFIELD
1 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
I HEREBY CERTIFY THAT I 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 T GAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI PROP TY. BACKFILL SEPTIC TANKS [ISIGNATURE
SEEP. PITS) CESSPOOLS
OF P
®r VALIDATION ROBERT A.WOOD
M
DX. K.D. usR SUPERVISING ECHAA NICAL ENGINEER
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