HomeMy Public PortalAbout5324 BALDWIN AVE_Sewer__ (2) D
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APPLICATION FOR PERMIT 1
s&E DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engmeer
County of Los Angeles BUILDIADDRENG
5324 N. Baldwin Ave, ,
JOHN A LAMBIE COUNTY ENGINEER
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY Temple City
FOR APPLICANT TO FILL IN CROSS ST Olive Avenue
LEGAL n
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DESCRIPTION LOT NO / OWNER ARR Con struntion (,nrnnany
Al L
BLOCK TRACT �� IF S ADDRESS 302-E. Huntington Dr. ,
NO OF BLDGS (,+
SIZE OF LOT a NOW ON LOT CITY a� �.C1.+ 10
Arcadia � TEL NOR
USE OF u
BUILDINGS r DISTRICT NO GP I MAP
BK PG
CONTRACTOR
CONNECTION DATA
ADDRESS 310 E. Huntington Dr. ,
CITY AX'Ca.diB TEL NO HI..,�.-�1�•�•6 STATION DEPTH
MANHOLE REF RENCE _ d PPER
� STATE
REGISTRATION NO 77810 1 ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTIONLENGTH FROM
1 PUBLIC SEWER @ 00 Y CURB P L M L TOP L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE Q $2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO�/y L//►
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER S PERMIT s Oo
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE 5 00
IHAVE 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 A� o 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
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 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,) AM THE LEGAL 0 NER OF THE ABOVE
DESCRIBED RESIDENT AL PROP BACKFILL SEPTIC TANKS❑
SIGNATURE /� SEEP PITS) ❑ CESSPOOLS❑
OF PERMITT E
JOHN A LAMBIE COUNTY ENGINEER ALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK N 0 CASH
1� 08 5 3 1S ItiR 30 1 J A 5 00kr