HomeMy Public PortalAbout4845 BALDWIN AVE_Sewer__ (2) 6A64 2D,062
7APPLICATION FOR PERMIT
8A84
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Eng n B ADDRESS
WILLIAM A JENSEN Sup t of Bu lcImg
LOCALITY
rDDNEAREST
R PPLICANT TO FILL IN CROSS ST
T IoO 11411 P OT NO IQ OWNER
MAIL
41 TRACT � ADDRESS
NO OF BLDGS
LNOW ON LOT CITY TEL NO
GS DISTRICTNO GROUP MAPPROCESSEDBY
PG
TOR BK 7"� CONNECTIOON DATA
TEL
NO ❑ ION PTH
STATE MANHOLE REFERENCE
IVI
REGISTRATION NO COUNTY OWER
NO DESCRIPTION OF WORK FEE TYP OF NECTION LENGTH FROM a
HOUSE SEWER CONNECTING TO r �/ P L ML TO P Llet O
PUBLIC SEWER @ S5 00 J! i
3L
SEPTIC TANK SEEPAGE PIT OR /Vl JP C NO
NO U
CO IMP NO
PITS AND/OR DRAINFIELD @ E1000 A �y �
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO 7
PRIVTE DISPOSAL SYSTEM @ $3 00
CONNECT DDITIONAL BLDG OR AFFIDAVIT RECORD INSTR NO DATE W
WORK TO HOUSE SEWER @ S3 00 d
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ 55 00HWY OR ST WIDENING dD ��TV
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ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
NDUSTRIAL
WASTE AP ROVAL
OWNERS PERMIT $ z 00 CHARGES
AUTHORIZATION TOTAL FEE
,,,o CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO L C SEWER CONNECT THE ABOVE DESCRIBED EXISTING DWELL NG APPROVALS
TO THE PU DATEn INSPECTO1 S SIGNA URGE
SIGNED THIS DAY OF 19_
OWNER OR _ / NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
HEREBY ACKNOWLEDGE THAT I HAVEREAD 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 ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
C LIFORN IA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE ACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
CK M O CASH
SUPERVISING MECHANICAL ENGINEER
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78A APPLICATION FOR PERMIT
8AG42D0 84
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING / '-
JOHN A LAMBIE County Eng ne ADDRESS (�J
WILLIAM A JENSEN Sup t of Buildrng
LOCALITY
NEAREST
F APPLICANT TO FILL IN CROSS S , �"
DES I I T O OWNER ,
MAIL
B T ADDRESS D /
OF EI
E L OW ON LOT 3 CITY TEL NO
USE OF W�"� DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
�{BK PG
CONTRACTORJV S Off' 17 Y T. Goy�r—L�o
ADDRESS CONNECTION DATA
CITY h TEL NO 1, GQ ION -I fiY " DEPTH
❑ STATE MANHOLE REFERENCE
REGISTRATION NO ❑ COUNTY I zi0r A/
LOV♦kER
NO DESCRIPTION OF WORK FEE ypE OF O TON LENGTH FROM d
HOUSE SEWER CONNECTING TO Y P L M L TOP
L '�- O
PUBLIC SEWER @ $5 00 P C NO 0
SEPTIC TANK SEEPAGE PIT OR '2
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO J JOB NOix
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO q FY8'7 o
PRIVATE DISPOSAL SYSTEM @ $3 Do
CONNECT ADDITIONAL BLDG OR AFFIDAVIT w RECORD INSTR NO DATE W
WORK TO HOUSE SEWER @ $300 d
OVERFLOW SEEPAGE PIT DRAINFIELD h
EXTN CESSPOOL DRYWELL MANHOLE @ $500 Z
ALTER REPAIR OR ABANDON HOUSE
HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
OA PERMIT NO
NDU TRIAL /
WASTE APPROVAL f
CHARGES
OWNERS PERMIT s o
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Z S�
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
T ACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBL C SEWER APPROVALS DATE INSP CTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR / NEW HOUSE SEWER
OWNERS AGENT_�T�,
CONNECT ADD T ONAL
DDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
NO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
C LIFORNIA OR THAT I AM T E LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE ES RIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATIOI ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
f� 1 S O 44 5 1 1 D J