HomeMy Public PortalAbout5222 BALDWIN AVE_Sewer__ D
S&E 663 12 S4 APPLICATION FOR PERMIT 7
1 5 8 E 81
DIVISION OF WELDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
WM J FOX *LINTY ENGINEER ADDRESS
CASSATT D GRIFFIN SUP T or BUILDING LOCALITY
F APPLI ANT TO FILL IN NEAREST '
CROSS ST
LEGAL jj
DESCRIPTION LOT N /GWNER / /V ✓r
BLOCK TRACT MAIL
ADDRESS ✓��o' A .(rLto— G!�Y
NO OF BLDGS
SIZE OF LOT (f NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP BK MAPG
P
,r�
CONTRACTOR
ADDRESS U CONNECTION DATA �Y
CITY �T/�/�idl�.V'•�9 TEL NO �,,���/j ��,JO SrTA�TION �f /�t�, 24 JDEPTH
,
STATE
,/-?C�� _Q " ❑�::Y __ //�� /"� ' -5,r2?
� UPPER NHOLE REFERENCE
REGISTRATION NO J
TYPE OF CONNE I LENGTH FROM
NO DESCRIPTION OF WORK FEE Y CURB P L M L TO P L
HOUSE SEWER CONNECTING TO 1.1-7 0-40
PUBLIC SEWER Q § 3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 <<
CONNECT ADDITIONAL BLDG OR CO IMP NO / ,f JOB NO
_ WORK TO HOUSE SEWER 1 00 —.r
ALTER OR REPAIR EXISTING ff
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO I/'RCAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHME !!
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
--PITS AND/OR DPAINFIELD 2 00 F
CESSPOOL DRYWELL STE APPROVAL '
SPECIAL CONDITIONS ONLY 2 00 CHARGES�h
PERMIT C NNE I�A G� LiEf US r
OWNF,R$ $ 1 00 L ea 3 B e Baft e
AUTHORIZATION TOTAL FEE R IMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMID CON URE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING 1110 v
TO THE PUBLIC SEWER
SIGNED THIS DA19 NEW HOUSE SEWER iZ
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[IDRYWELL ElAND 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 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SEEP PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTEE `
WILLIAM J FOX COUNTY ENGINEER y VALIDATION
BY
_NCO 6 9 BY 2 ?, Aus 19 4 450 in
!
DEPUTY ' DEPUTY
BY BY
s® DEPUTY DEPUTY