HomeMy Public PortalAbout5409 ROBINHOOD AVE_Sewer__ 7SA6420
E-669 11. 5 APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING ���y
9 Rb
JOHN A. LAMBIE. COUNTY ENGINEER _ADDRESS (9�Ys_ ()Pt]oj6��� (� y�j]uE�,��
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY yea le Ci V
FOR APPLICANT TO FILL IN NEAREST
cRoss s__ y,,� `.]..°t�LP.P _
LEGAL
DESCRIPTION LOT NO,---•--------- -- -- --- --- OWNER._.. O11LL R. gert .ry
l,d.MAIL
---
BLOCK TRACT 21704 ADDRESS
NO. OF BLDGS.
S CITY Covina TEL. NO.
-iZ _E OF LOT_ _— NOW ON L07
USE OF Residence DISTRICT NO. GROUP MAP
BUILDINGS yS-L pp.�1!!_qr _ I BK PG
CONTRACTOR L-D-PAT. {ionst.Lunt on. f,10®-- ` -
ADDREsSL`-. 0. Box 208 _-- --._ CONNECTION DATA
�°tpyry '� n STATION .yfri c
CITYJ3�...t.dCIG�.n .Park TEL. NO. ED 8-30.C�I- �;` DEATH "�• _ _
- yy MANHOLE REFERENCE y `#�
�3.T STATE —�_ _.:.e' �"_..=,>'.P? R LOWER .I
REGISTRATION N0. 3 E] COUNTY _.,.._..
NO. I DESCRIPTION OF WORK FEE — -- — -
--� - -- - TYPE OF CONNECT10ti q;, LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L.d M.L.TO P.L.
PUBLIC SEWER _ -- � $3,5D --- � ' d---y- - =--
SEPTICTANK,
PITS-AND/OR DRAINFIELD Cq $:3,00
—t --—
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. NO.
E7t7N•,GLSSPOOL,DRYWELL,MANHOLE n $ 2.00 CO. IMP. NCI.----- JOB N0. y' g`�.✓:?
HOUSE SEWER CONNECTING TO -
_ PRIVATE DISPOSAL SYSTEM (k $1.00_ _P.U_NK PERMIT NO. _- ROAD PERMIT NO_,____�-
j CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEF FR Ct? $1.00 PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM (4 $1.00 INDUSTRIAL
_ _ WASTE APPROVAL
CHARGES
i 1
L-_._-- CONNECTION CHARGE FEE
OWNER'S PERMIT $ ao --- ---------- -
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE.
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- __._.APPROVALS_- DAT£-INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THF' ABOVE DESCRIBED EXISTING DWELLING —�
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS .DAY OF---19 CONNECT ADDITIONAL
OWNER OR3U
7�7 ILDING OR_W ORK__ _ _)
OWNERS AGENT t-YAW _ .— SEPTIC TANK,SEEP,PIT(S) -
,ADDRESS-_____ AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL CJ DRYWELL EJ -{i
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING VALTER REPAIR ER
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM I _
I HEREBY CERTIFY THAT I Ab! PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS AtiGGE'�ES COUNTY AND STAT'kOF !
CALIFORNIA OR THAT I AM THE 'CE$AL OWNER OF THE ABOV ABANDON HOUSE SEWER
DESCRIBEDRESIDENTA !?:OPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE / -,l.y - SEEP,PIT(S) L] CESSPOOL$Q
OF PEP.MCT7E Y ---. __ - ----- -�---�
f i
IOHN A. LAMBIE,COUNTY EXGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
t>'C-9 M. c. CASH ,
1 F` :1 5 I t ri s a ti '�� .� 0 A
5.00 r,
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