HomeMy Public PortalAbout4831 BALDWIN AVE_Sewer__ (2) 2/70
76A6A 642D APPLICATION FOR PERMIT
6
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL Ifl
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS 1 I n,
COLEMAN W JENKINS SUP T OF BUILDING /
LOCALITY
NEAREST
09 APPLICANT TO FILL IN /
CROSS 57
(PRINT OR TYPE ONLY)
LEGAL
DESCRIPTION LOT NO OWNER
/ MAIL
BLOCK TRACT CC ADDRESS
NO OF LDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP CLASS I MAP ESSED BYBKpr: -PR
CONTRACTOR
ADDRESS /� L, CONNECTION DATA `
CITY TEL NO /`j �I STATIONDEPTH C='
UPPER
STATE G LIC /�-r MANHOLE REFERENCE
LICENSE NO CLASS
NO DESCRIPTION OF WORK FEE TYPE OFC ION LENGTH FROM
HOUSE SEWER CONNECTING TO Y O=
P L ML TOP L
PUBLIC SEWER @ $5 00 t/ C
SEPTIC FANK SEEPAGE PIT OR �� P C NO
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
TRUNK PERMIT NO ROAD PERMIT NO lA" �a / }
PRIVATE DISPOSAL SYSTEM @ $300 0-
CONNECT
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIY[R I [AS[Y[NT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER $300 U
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 HWY OR ST WIDENING 0
ALTER REPAIR OR ABANDON HOUSE H
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT V
PERMIT NO W
CL
INDUSTRIAL N
WASTE APPROVAL Z
CHARGES
OWNER S PERMIT s Oo
AUTHORIZATION TOTAL FEE !. CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTO S SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER R/►
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANKSEEP PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY T"AT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR gy
LICENSED AS REOUIR /BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THA
Y, ll AHE LEGAL OWN R OF AND INTEND TO DISCONNECT PLUG AND f
RESIDE IN THE VE DESCRIBED RESIDE TI L PROPERTY ABANDON HOUSE SEWER
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IGNATURE //i1/ `/ BACKFILL SEPTIC TANKS ❑ al'
OF PERMITTEE I ',���VV SEEP PIT(S) ❑ CESSPOOLS ❑
CC
K ON JACK R ALLEN
KMCASH SUPERVISING MECHANICAL ENGINEER 1
LACO .45 FEB231 0 D 1000