HomeMy Public PortalAbout5414 BALDWIN AVE_Sewer__ (2) 7G
A64213
66
S g E BeAPPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engmeer
County of LOS Angeles BUILDING If_ A�
JOHN A LAMBIE COUNTY ENGINEER ADDRESS h� /
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
R APPLICANT TO FILL IN CROSS ST
LEGAL 3 V n C�
DESCRIPT LOT NO {'� 7/ OWNER e, ae
BLOCK TRACT �� ADDRESS
NO OF BLDGS
SIZE PF LOT ,Q i{i { NOW ON LOT CITY , TEL NO
USO
BUILDINGS G` DISTRICT NO GROUP MAP
PG
CONTRACTOR t ..ap...=�
04 0
s' T:, r - /
ADDRESS G CONNECTION DATA
�} STATION DEPTH
CITY TEL NO
MANHOLE REFERENCE UPPER
r ❑ STATE 16 LOWER
REGISTRATION NO 149 4 ❑ COUNTY /�
NO DESCRIPTION OF WORK FEE (J
HOUSE SEWER CONNECTING TOTYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3 50 Y CURB P L M L TO P L
SEPTIC TANK SEEPAGE PIT OR S /
PITS AND/OR DRAINFIELD Q $3 00 r
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
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 $100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE 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 ,E'lt'► .� . / ,/j BUILDING OR WORK
OWNERS AGENT 1 ,iY !-
SEPTIC TANK 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
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 RESIDENTI OPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP PIT(s) ❑ CESSPOOLS❑
OF PERMITTEE Z—
JOHN A LAMBIE COUNTY ENGINEER VALIDATIOROBERT A WOOD CHIEF PLBG INSPECTOR
CK EE 0 CASH
0 5 2 1 5- FEB 1 5J 4 2 0 0 'n