HomeMy Public PortalAbout4847 BALDWIN AVE_Sewer__ (2) 78A
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8 APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engmew _/ _
County Of LOS Angeles BUILDINrADDRESSG ' cZcP � �(� �r,e.JOHN,A LAMBIE COUNTY ENGINEERCASSATT D GRIFFIN SUP T OF BUILDING OCALITY /�rlfj�rJ� /'� •,,��
FOR APPLICANT TO FILL IN CROSS ST
LEGAL OWNER
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DESCRIPTION LOT NO
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT 3 NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP
BUILDINGS
KPG
CONTRALTO �
z _ $
ADDRESS CONNECTION DATA
SI`� STATION �Q • DEPTH
CITk" EL NO �J
MANHOLE REFERENCE SQ U
J , ! ATE LO ER
REGISTRATION NO / D , sL.l� COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEW.ER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEER @ $3 SO Y CURB P L M L TOP L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P CNO
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT N
CONNECT ADDITIONAL BLDG OR STATE ENCRO M T
WORK TO HOUSE SEWER @ $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVA 11
' CHARGES
CONNECTION CHARGE FEE
OWNER S PERMIT On
AUTHORIZATION TOTAL FEE , REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTICTANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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 I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEN IAL PROPE TY t r BACKFILL SEPTIC TANKS[:1SIGNATURE �y,/p SEEP PIT(S) [:1 CESSPOOLS[]
PERMITTE fib i ` •1 T
�I i.
JOHN A LAMBIE COUNTY ENGINEER ALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK N 0 CASH
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