City of Covina
Office Use Only
Environmental Services Section
Date Applied:
125 E. College St., Covina, CA 91723
Permit No.:
626) 384-5480 • Fax (626) 384-5479
Permit Approved By:
Swimming Pool Drainage Permit Application
(Must be returned to the Environmental Services Section, City Hall)
Site of Pool to be Drained
Property Owner/Tenant Name:
Address:
Cross Street: Phone:
Pool Service/Repair Company Information
Business Name:
Business Address:
Contact Name:
Business Phone: Business License Number:
Materials to be recycled and estimated monthly weight to be hauled - in Tons
Test Result Required Follow Up
Chlorine _______________________________ ____________________________________
pH (between 6.5 and 8.5) _______________________________ ____________________________________
Dirt _______________________________ ____________________________________
Leaves/Debris _______________________________ ____________________________________
Algae _______________________________ ____________________________________
_______________________________ ____________________________________
_______________________________ ____________________________________
Reason for draining:
Repairs being done and duration:
Date(s) of draining:
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE PRECEDING AND AGREE TO COMPLY WITH THE COVINA
MUNICIPAL CODE AS WELL AS ALL COUNTY, STATE, AND FEDERAL LAWS PERTAINING TO THE EXECUTION OF THIS
PERMIT. I ALSO CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
Name: ___________________________________________________________________ Date:___________________________________
Signature:________________________________________________________________
Revised 6-10
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