HomeMy Public PortalAbout5329 BALDWIN AVE_Sewer__ (2) j'2
&E 663 12 54
6 8 E 66APPLICATION FOR PERMIT 1
DMSION OF BUMDING AND SAFETY SEWER-SEWAGE DIS POS/ L.
Deportment of County Engineer
County of Los Angeles BUILDING E`� 7 0
WM J FOX COUNTY ENGINEER ADDRESS i ! (r(F
CASSATT 0 GRIFFIN SUP T OF BUILDING LOCALITY ' irn��
FOR APPLICANT TO FILL IN NEAREST ,�Ip _
CROSS ST �yGr—c C
LEGAL �2'
DESCRIPTION LOT NO 7s �- OWNER
BLOCK TRACT 075.5'S5 MAIL p�
�/ ✓� r S ADDRESS 6( �fll �:✓/YW... (.�(/�trC/4�(�,
SIZE OF LOT(I � C / NOW ON LOTCITY &T_c4i"A_ TEL NO OL J T�
USE OF
BUILDINGS DISTRICT NO GROUP MAP
CONTRACTORF— I P
ADDRESS '3 q�` CONNECTION DATA
CITY TEL NO A,'r7 / G 7 i STATION qt7l%, DEPTH Y
VV
[3 STATE L�� MANH FERENCE
REGISTRATION NO ❑ COUNTY �J
TYPE OF CONNECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE Y 1. M L TO P L
HOUSE SEWER CONNECTING TO C1iA
PUBLIC SCWER Q $ 3 50 �V
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 s�
CONNECT ADDITIONAL BLDG OR �O CO IMP NO J .6.7 JOB NO
WORK C HOUSE SEWER l 00
ALTER OR REPAIR EXISTING
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 TANK SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE D REIMBURSEMENT FEE
I HAVE DATETRACTORT TO CONNECT THEAABOVE DESCRIBED EXISTINGWITH THE HEREINA MED DWELL G APPROVALS DATE INSPECTOR SSIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR -7 '�� CONNECT ADDITIONAL
OWNERS AfG�ENT,�Q� vt�cctrtr-- BUILDING OR WORK
ADDRESS r�t '�'9" j SEPTIC TANK SEEP PIT(S)
L'�"- ��''� r 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 RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SEEP PITS) F-1CESSPOOLS[3SIGNATURE
OF PERMITTEE
WILLIAM J FOX COUNTY ENGINEER VALIDATION
BY _AC0+6Y 4 8 1 S JM 8 4 550 m
DEPUTY DEPU
BY BY
`® DEPUTY DEPUTY