HomeMy Public PortalAbout5614 HELEO AVE_Sewer__ gaOS.0
CAPPLICATION FOR PERMIT
eaos-e-ee COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING ADDRESS 5614 Hel eo
JOHN A. LAMBIE. County Engineer
CASSArr D. GRIFFIN. Sup't of Building LOCALITY Temple City
FOR APPLICANT TO FILL IN CROSS ST.
roe way
LEGAL ohn 8itzgerald
DESCRIPTION LOT N0. � OWNER .T R
BLOCK TRACT 2>202 MAIL
ADDRESS 21121 Mesa Rica Road
N0.OF BLOTS. Covina EI Tl 2�r/925
SIZE OF LOT NOW ON LOT CITY TEL.N0. lilt // JG
USE OF
BUILDINGS Res. DISTRICT NO. GROUP MAP �P.RDCESSED BY
CONTRACTOR
ons ruc iOn BK PG J1
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ADORE$$$$ CONNECTION DATA
3i8t$�$1$ 1 4 _
CITY TEL. NO. jell O� UC4 STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. B COUNTY s�
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER G $3.00
SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM /
PITS AND/OR DRAINFIELD 0 $3.00 Y. CURB -P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESS POOL,DRYWELL.MANHOLE a $2.00
HOUSE SEWER CONNECTING TO P.G. N0. ^7
PRIVATE DISPOSAL SYSTEM ® $1.00 CO.IMP.NO. JOB N0. l
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
SEWER OR DISPOSAL SYSTEM TER, REPAIR OR ABANDON HOUSE @ $I OO STATE ENCROACHMENT
PERMIT N0.
IN
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 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. (;
SIGNED THIS DAY OF IB_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERSAGENi Rw BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 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
IICHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LENSED AS REQUIRED BY LOS AN LES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM TNS-EGAEy
OWNER OF THE ABOVE
DESCRIBED RESIDENTI P - // BACKFILL SEPTIC TANK$ El
- /I f'` SEEP. PITS ❑ CESSPOOLS
OF PERMITTE C
®r / 7DATION _ ROBERTA.WOOD
(:K. B.V. CASH SUPERVISING MECHANICAL ENGINEER
09 0 og 1 o A 5.0 0
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