HomeMy Public PortalAbout4841 BALDWIN AVE_Sewer__ S&E48 311 55 APPLICATION FOR PERMIT 7
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL 1
Department of County Engineer
County of LOS Angeles BUILDING /f`
JOHN A LAMBIE COUNTY ENGINEER ADDRESS45
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS Sr •�prt�U Vii" Q�f�� 7 /6 .
LEGL
DESCRIPTION LOT NO /Qn `� OWNER
A�� MAIL
BLOCK TRACT "pAADDRESS
NO OF BLDGS _ / CITY TEL NO
SIZE OF LOT 1D4VNOW ON LOT
USE OF C� �✓ DISTRICT NO GROUP MAP
BUILDINGS /( Li' Y`'`
eBK PG�
CONTRACTOR�j
ADDRESS,,�O/�Y G' CONNECTION DATA
STATION , O DEPTH ,
CITY L NO �f �!'�/ ,.{ /
MANHOLE REFERENCE �J
REGISTRATION NO 061�j [1 COUNTY
/ LOWER
❑ COUNTY a
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO �'
PUBLIC SEWER @ $3 50 CURB P L M L TOP L��j
SEPTIC TANK SEEPAGE PIT OR +
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELDP C NO
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00 CO IMP NO ��� !OB NO
HOUSE SEWER CONNECTING TO )D
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO //
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL Y
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL
C�ARGES
CONNECTION CHARGE FEE
OWNER S pERMT s 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE C>
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 —�Z/ DAY OF ��� 19` � CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTICTANK SEEP PIT(S)
ADDRESS t ,¢G. 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 SEWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AN
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF D
ABANDON HOUSE SEW D
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RES]DENTI PROPERTY BACKFILL SEPTIC TANKS ^'
SIGNATURE SEEP PIT(S) C1 CESSPOOLS CESSPOOLS❑
OF PERMITTEE
C-Ef 6�0(
JOHN A LAMBIE COUNTY ENGINEER� VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK M 0 CASH
LACO 4 4 2 4 JAN 2 3 4 450 In