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HomeMy Public PortalAbout5414 BALDWIN AVE_Sewer__ 7G A64213 66 S g E BeAPPLICATION FOR PERMIT 1 DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL Department of County Engmeer County of LOS Angeles BUILDING If_ A� JOHN A LAMBIE COUNTY ENGINEER ADDRESS h� / ® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY R APPLICANT TO FILL IN CROSS ST LEGAL 3 V n C� DESCRIPT LOT NO {'� 7/ OWNER e, ae BLOCK TRACT �� ADDRESS NO OF BLDGS SIZE PF LOT ,Q i{i { NOW ON LOT CITY , TEL NO USO BUILDINGS G` DISTRICT NO GROUP MAP PG CONTRACTOR t ..ap...=� 04 0 s' T:, r - / ADDRESS G CONNECTION DATA �} STATION DEPTH CITY TEL NO MANHOLE REFERENCE UPPER r ❑ STATE 16 LOWER REGISTRATION NO 149 4 ❑ COUNTY /� NO DESCRIPTION OF WORK FEE (J HOUSE SEWER CONNECTING TOTYPE OF CONNECTION LENGTH FROM PUBLIC SEWER @ $3 50 Y CURB P L M L TO P L SEPTIC TANK SEEPAGE PIT OR S / PITS AND/OR DRAINFIELD Q $3 00 r OVERFLOW SEEPAGE PIT DRAINFIELD P C NO EXTN CESSPOOL DRYWELL MANHOLE Q $2 00 CO IMP NO JOB NO HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT WORK TO HOUSE SEWER Q $1 00 PERMIT NO ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM Q $100 WASTE APPROVAL CHARGES CONNECTION CHARGE FEE OWNER S PERMIT $ 1 00 AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER NEW HOUSE SEWER SIGNED THIS DAY OF 19 CONNECT ADDITIONAL OWNER OR ,E'lt'► .� . / ,/j BUILDING OR WORK OWNERS AGENT 1 ,iY !- SEPTIC TANK SEEP PIT(S) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ AND 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 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 RESIDENTI OPERTY BACKFILL SEPTIC TANKS❑ SIGNATURE SEEP PIT(s) ❑ CESSPOOLS❑ OF PERMITTEE Z— JOHN A LAMBIE COUNTY ENGINEER VALIDATIOROBERT A WOOD CHIEF PLBG INSPECTOR CK EE 0 CASH 0 5 2 1 5- FEB 1 5J 4 2 0 0 'n