HomeMy Public PortalAbout5130 BALDWIN AVE_Sewer__ DEPA .CMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
_DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
e COUNTY OF LOS ANGELES //
WILLIAM J FOX COUNTY ENGINEER BUILDING ADDRESS J � �
1F_OR APPLICANT TO FILL IN LOCALITY 1'7 ""A/MBUIL ��
,1 NEAREST
AD DRFa.7 /{� � CROSSST �(,l� Ij
LOCALITY l L DISTRICT NO SERIAL NO PERMIT NO
NEAREST
CROSS ST
OWNER Ati�i 4.1 ��,�� RECEIVED BY Ready for In3piction DATE ISSUED
MAIL
ADDRESS .3f &j/p� USE ZONyE- OCCU�PANICY BK MAP PG
CITY �ib�f q�� �Q EL NO ✓ I / /) /R r-
CONTRACTOR ��j C/
/� CO IMP NO
ADDRESS 6.: > � ^' - JOB NO Ttk Pef N
1/�,/ ,,
CITY ! TEL NO '7 . s TRUNK PERMIT NO--// Running Trap or Gas Trap
REGISTRATION NO �� rRequired
COUATENTY
ROAD PERMIT NO
LEGAL
DESCRIPTION LOT NOS• L.l 40q�_ STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT JV440 Il / i INDUSTRIAL '
WASTE APPROVAL
SIZE OF LOT NO OF BLDGS
NOW ON LOT CHARGES
USE OF I
BUILDINGS t,(,9��//$���— CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE e�
HOUSE SEWER CONNECTING TOrg REIMBURSEMENT FEE
PUBLIC SEWER Q $ 350 z 7 �� RECEIPT NO DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING NO DATE I BY
SEWER OR DISPOSAL SYSTEM 1 00 -
DISCONNECT
OISPOSAL SYSTEMN SEWER
AND/OR 1 00 _„),/,d.�4
,�,r,��CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 200 STATIOt��Q7� DEPTH r
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 MANHOLE REFERENCE
/1�11 UPPER Low"
c
TYPt OF CONNECTION LENGTH FROM
Y-_ Afc
OWNERS PERMIT $ 1 00 " CURB P L M L TO P L' J
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR S SIGNATURE DATE
DWELLING TO THE,pjJBLIC SEWER
SIGNED THIS tLJ' DAY OF I9,V NEW HOUSE SEWER
OWNER OR { e7;� - la - CONNECT ADDITIONAL
OWNERS AGENT LLL �'la y'v�* BUILDING OR WORK
ADDRESS _ SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL[] DRYWELL
CATION AHD STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
\ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED N
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ARAN DISCODONECT PLUG AND
N HOUSE S EWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN
ER OF THE ABOVE ��� D RE31D�T A PROPERTY�� BACKFILL SEPTIC TANKST
SIGNATURE SEEP PIT(S) CESSPOOLS
OF PERMITTEE iii
76A642D 663 1/53