HomeMy Public PortalAbout5131 BALDWIN AVE_Sewer__ (2) D
S&E6APPLICATION FOR PERMIT 1
8$s DMSION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of LOS Angeles BUILDING
ADDRESS
WM J FOX COUNTY ENGINEER
CASSATT D GRIFFIN SUP T OP BUILDING LOCALITY
FOR APPLICANT TO FML IN NEAREST ti
CROSS ST � � �� t
LEGAL y� h
DESCRIPTION LOT NO OWNER
BLOCK TRACT V-V-a MAIL
ADDRESS
SIZE OF LOT �OONO OF BLDGS /
O NOW ON LOT / CITY TEL NO c 6
USE OF .�
BUILDINGS DISTRICT NO GROUPI MAP
S✓ T_ BK PG
CONTRACTOR a ta — Q
ADDRESSS �'� CONNECTION DATAyv
CITY v/�„_ TEL N STATION / *S DEPTH
70al STATE MANHOLE REFERENCE 7 1 J ^Q u UPPE
REGISTRATION NO ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE Of CONNECTION LENGTH FROM meq,
PUBLIC SEWER Q $ 3 50 Y CURB P L M L TO P L /(/
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 _
CONNECT ADDITIONAL BLDG ORP C NO
_WORK TO HOUSE SEWER 1 00 CO IMP NO/305- JOB NO
ALTER OR REPAIR EXISTING NO
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANV SEEPAGE PIT OR
ITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL DRYWELL
WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
OWNER S PERMIT5 1 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE �0 REIMBURSEMENT FEE
MED CON
TRACTORHAVE TTOS DATE CONNECT THEACTED ABOVEWITH D ES IB D EX ESTINGIN A DW ELL G APPROVALS DATE INSPECTORS 5 GNATURE
TO THE PUBLIC SEWER
NEW HOUSE SEWER ,�/
SIGNED THIS_-DAY OF 19_ r-,
/l
OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR NORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE REA HIS APPLICATION CESSPOOL[I DRYWELL[IAND STATE THAT THE ABOVE IS CORRECT AN GREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STAT AWS REGULATING ALTER REPAIR SEWER OR
LCALIFORNIA
AND SEWERS SEWAGE DISPOSAL SYSTEM
CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
S REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKSSEEP PITS) ❑ CESSPOOLSTTEE
WILLIAM J F X COUNTY ENGINEER VALWATION R A WOOD CHIEF PLBG INSPECTOR
I�;o 1 8 3 7.; SEP 1? 4 450
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