HomeMy Public PortalAbout4923 BALDWIN AVE_Sewer__ r
`r.80e21 57 2D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING '�� `
JOHN A LANBIE county En eer ADDRESS 923117a13dWien ave°
cASSATT D GRIFFIN Supt of Buddmg LOCALITY `Temple City
FOR APP CANT TO FILL IN
NEAREST
LEGAL a- 7— 21 a/ OWNER Weber Construction Co.
DESCRIPTION LOT NO
BLOCK TRACT r7,g �f MAIL an a rie V .
ADDRESS
NO OF SIZE OF LOT NOW ON LOTS 1 CITY San abrielTEL NO Calif*
USE OF
DI Residence
BUILDINGS pAg DISTRICT 0 I GROUP I MAP
CONTRACTOR✓Z.D.° . Con@traction -u �PG
ADDRESS A� BOX 208 CONNECTION DATA
CITY I.—Baldwin a NO a ° 85024 STATION DEPTHSTATE /
REGISTRATION NO 113613 //3,ad. I COUNTY MANHOLE REFERENCE
LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER (� $S 50 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L
ITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR I
WORK TO HOUSE SEWER @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERNIIT $ 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 5 100 REIMBURSEMENT FEE
1 HAVE AT THIS DATE-A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTORS St.GNATURE _.
TO THE PUBLIC SEWER ✓ �/_ _ _ w _ _ -
SIGNED THIS DAY OF 19- NEW HOUSE SEWER 3!G
OWNER OR- �I eW '- - - - "CONNECT ADDITIONAL -
OWNERS AGENT BUILDING OR WORK
ADDRESS '-' - SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE-TO COMPLY CESSPOOL-❑-DRYWELL❑ "
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS -
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED'RESIDEI`gJAL PROP RTY BACKFILL SEPTIC TANKS ❑ /
SIGNATURE / '' SEEP PIT(S) El CESSPOOLS Eln (/4
OF PERMITTE �O
V
cAUDATION ROBERT A—WOOD
_ �w
u 0 cesH SUPERVISING MECHANICAL ENGINEER
I 3366 F,kR121 0 A