HomeMy Public PortalAbout4848 BALDWIN AVE_Sewer__ (2) 7aweaHD
889958 APPLICATION FOR PERMIT
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DMSION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer mmomm
County of Los Angeles 7771
WM J FOX COUNTY ENGINEER fA7DDRESSCASSATT D GRIFFIN SUP T OF BUILDING FOR APPLICANT TO FILL IN B eu'c,Y�/ �9CROSS ST LEGAL45T�4 �?J� e) � 1�-DESj RIPTION /V' OWNER ♦A/TRACT t, lC�/ J / ' (d O ADDRESS O VSIZE OF LOT ��77��../ ry S (J NO OF BLDGS �' -
Ta X.L NOWq LOT. CITY ie'poo (d TEL NO . p'2 , i
USE OF
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But NGS Chu IeS 4 / �U L/-S �� �d ��� DISTRICT NO GROUP MAP
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CONTRACTOR S "S'eLd �' 7-- f 1
ADDPESS CONNECTION DATA
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CITY/4/10 i 061 TEL NO 0o 7- Vp7ST TION DLPTH
/ -� STATE MANH REFERENCE UPPER
REGISTRATION NO / 14, 1,3 y ❑ COUNTY A LOWER
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NO DESCRIPTION OF WORK FEE
YPE OF CONNE ION LNG ROA1
HOUSE SEWER CONNECTING TO Y CURB 1 L M 0 L
PUBLIC SEWER @ $ 3 50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR C NO
WORK TO HOUSE SEWER 1 00 CO IMP NO J NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD P IT NO
DISCONNECT AND ABANDON SEWERSTATE ENCROACHA
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AND/OR IJISPOSAL SYSTEiA 1 00 Q PERIVIT NO
SEPTIC TANK SEEPAGE PIT OR /-
PITS AND/OR DRAINFIELD __300 m� INDUSTRIAL
CESSPOOL DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00
� CHARGES
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OWNER S PERMIT C NECTION CHARGE FEE
AUTHORIZATION TOTAL FEE a�a� REIMBURSEMENT FE W/ld
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON ,
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING D15ELLING APPROVALS DATE INSPECTOR SSIGNATURE
TO THE PUBLIC SEWER o
SIGNED TFIIS _DAY OF 19 INEW hOUSE SEWER
OWNER OR (CONNECT ADDITIONAL /
OWNERS AGENT IBUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS LAND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE ThAT I HAVE READ THIS APPLICATION CESSPOOL DRYWELL❑ . �
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS R
ALTER REPAIR SEWER
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SY
R OOR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THA 1 AM OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDE AL PR 9ER BACKFILL SEPTIC TANKS❑
SEEP PIT(S) [I CESSPOOLS❑
SIGNATURE
OF PERMITTEE
WILLIAM J FOX COUNTY ENGINEER VALIDATION R A WOOD CHIEF PLBG INSPECTOR
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