HomeMy Public PortalAbout5139 BALDWIN AVE_Sewer__ D
5&E 663 12 34
APPLICATION FOR PERMIT
5&E 6
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engmeer
County of Los Angeles BUILDING
WM J FOX COUNTY ENGINEER ADDRESS
CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER ��y/�'Gr.�e�,.!► h
BLOCK TRACT 1 2 RIC MAIL
ADDRESS
NO OF BLDG-
SIZE OF LOT NOW ON LOT CITY L° TEL NO
USE OF
BUILDINGS ,121 DISTRICT NO GROUP MAP
BK PG
CONTRACTOR
ADDRESSD�� �j COIQ,N�ECTION DATA
CITY � TEL NO ��� STATION A(�J�Z{3 .V DEPTH ,
STATE 17 M FERENCE
REGISTRATION NO ��30f C3 COUNTY ,7L�� �Q USP rci> e
TY OF CONNECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE Y CURB P L M L TO P L
HOUSE SEWER CONNECTING TO rO
PUBLIC SEWER Q $ 3 50 ..7
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 100 _
B NO
CONNECT ADDITIONAL BLDG OR CO IMP NO 13 0'3
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ,�"— ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 100 STATE ENCROACHMENT
PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
_ P TS 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 I TOTAL FEE "�f A REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONY J,
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIG ATURE
TO THE PUBLIC SEWER �
SIGNED THIS DAY OF 7P/ . 19� NEW HOUSE SEWER
✓U/
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS i AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL ElDRYWELL[3AND 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
IHEREBY 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❑
TS) ❑
SEEP PICESSPOOLS
SIGNATURE
OF PERMITTEE L
WILLIAM J FOX COUNTY ENGINEER VALIDATION
!o4 3-5 8� juN 6 4 450
BY a BY _074 —
DEPUTY x/,r�� DEPUTY
BY BY I 4
® DEPUTY DEPUTY