HomeMy Public PortalAbout5223 BALDWIN AVE_Sewer__ C660an 57 APPLICATION FOR PERMIT w` 1
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMCounty Engineer ADDRESS L f/V �-
C ATP D GRIFFIN Supt of Building LOCALITY:::::Z ' y Lk
4
NEAREST
FOR APPLICANT TO FILL IN CROSS STLEAL
- /,4
DE CRIPTION LOT NO �".�� / OWNER of
BLOCK TRACT !ro MAIL
ADDRESS
L� ^ NO OF BLDGS
SIZE OF LOT _
NOW ON LOT CITYTEL NO
USE OF
BUILDINGS L� DISTRICT NO
GROUP MAP
CONTRACTOR Q/160
ADDRESS c Ta s CONNECTION DATA
a 7F ' S fb3a._ p-
CITY TEL NO STATION DEPTH
REGISTRATION NO
-7f� !/) STATE MANHOLE REFERENCE UP
(_ OWER
No DESCRIPTION OF WORK FEE \
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3YPE OF CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00 CURB P L M L TOP L
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE Q $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT WORK TO HOUSE BLDG OR
SEWER @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO / 9
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
i WASTE APPROVAL
CHARGES
OWNERS PERMIT $ JL 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE _ O REIMBURSEMENT FEE
I HAVE AT THIS-DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC SEWER L� _
SIGNED THIS DA� d 19�L NEW HOUSE SEWER` /Y y
OWNER OR - _ CONNECT ADDITIONAL-
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS- ' - AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND-AGREE TO-COMPLY iCESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS ALTER REPAIR SEWER OR
1 HEREBY CERTIFY THAT I AM-PROPERLY REGISTERED AND/OR- SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELE COUNTY ND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR AM THE LE OWN OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RE DENP OP*ERTY BACKFILL SEPTIC TANKS❑ _
SIGNATURE I SEEP PIT(S) ❑ CESSPOOLSOgg
OF PERMITTE
®" ALIDATION ROBERT—A WOOD
cK n e 0-7- _ cAsx__ __ SUPERVISING MECHANICAL ENGINEER ^y
�LAU,D2 5 3 3 S FEB 17-1 0 A 500 to