HomeMy Public PortalAbout5104 BALDWIN AVE_Sewer__ (2) TEMPLE CHTY
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CE808 8 ®9 APPLICATION FOR PERMIT
H909 7
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING p
ADDRESS � V�
OHN A LAMBIE County Kn eer
C TT D GRIFFIN Supt of Building LOCALITY
NEARET
S
FOR APPLICANT TO FILL IN CROSS T s
LEGAL
DESCRIPTION LOT NO 3()f OWNER (! ,S
BLOCK TRACT MAIL
�sa2 ADDRESS 9
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS IfA65 j D e4,14.e DISTRICT NO I GROUP BK MAP P6 I PROCESSED BY
CONTRACTOR Td L,�- ,
ADDRESS !I ' CONNECTION DATA
CITY , TEL NO STATION 14 DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO 8 COUNTY LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ 400 TYPE OF TION LENGTH FROM
SEPTIC TA,NK SEEPAGE PIT OR Y C RB P L M L TO P L V
PITS AND/OR DRAINFIELD @ S 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $ 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $100 CO IMP NO JOB NO
WORKOOOEISEEBLDG OR
THOUSE SEWER @ 00 TRUNK PERMIT NO ROAD PERMIT NO
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWEROR DISPOSAL SYSTEM @ 100 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION FTOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATEI INSPECTOR S SIG A]'URE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
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 ANGELES C UNTY AND STATE OF ABANDON HOUSE SEWER I
CALIFORNIA OR THAT 1 AM THE L AL NER OF THE ABOVE �J
DESCRIBED TIAL PROPERTY SEEP BACKFPIT(ILL SEPTICCESSPOOLL3 ! l�/�' C✓'�
SIGNATURE /
OF PERM ITTE
VALIDATION ROBERT A WOOD F
g 0 CASH SUPERVISING MECHANICAL ENGINEER
UAu0 6 2 7 3% OCT 3 1 1 0 D 70 Q N x