HomeMy Public PortalAbout5638 HELEO AVE_Sewer__ T'ASA°n
csaoeese APPLICATION FOR PERMIT 1
COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 5638 Heleo
JOHN A. LAMBIE. County E gin..r ADDRESS
CASSATT D. GRIFFIN, Supt of Building LOCALITY. Temple' City
NEAREST Broadway
FOR APPLICANT TO FlU IN CROSS ST.
LEGAL o n i 21121 Mesa Rica Ro
zger
DESCRIPTION LOT NO. OWNER
BLOCK TRACT 25202 MAIL
ADDRESS
No. OF BLOT COVin TEL. NO. ED 2- 2
SIZE OF LOT NOW ON LOT CITY
USE OF T
BUILDINGS . e s• DISTRICT NO. GROUP BK MAP PG PROCESSED BY
CONTRALTO • I• onstruction Co
ADDRESS 5136 ee er CONNECTION DATA
cITYBaldwin Park TEL. No. ED 8- 024 STATION p DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION .LENGTH FROM %
PITS AND/OR DRAINFIELD ($ $3.00 Y. CURB P.L. M.L.
TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD -
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO. ��2
PRIVATE DISPOSAL SYSTEM /g $1.00 CO.IMP.NO. JOB NO, rJ
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
SEWER OR PAIR O AL SYSTEM HOUSE $1 00 STATE ENCROACHMENT
ABANDON PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ _ Z CD CONNECTION CHARGE FEE
AUTHORIZATION ITOTAL FEE REIMBURSEMENT FEE
I 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 19_ NEW HOUSESEWER
OWNER OR NEW W CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP,PITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 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 AN COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM TH E WNER F THE/�B0VE
DESCRIBED RESIDENT ROP Y. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PIT(5) [I CESSPOOLS [I
OF PERMITTE
®r - AIMATION ROSERTA.WOOD _
cX. Y.o. CASH SUPERVISING MECHANICAL ENGINEER
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