HomeMy Public PortalAbout4935 BALDWIN AVE_Sewer__ (2) 3 64
76A64 2D APPLICAT N FOR PE IT
6A64
COUNTY OF LOS ANGELES SEWER—SEWAG DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING <
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Buildmg
LOCAL TY
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T
LEGAL "7 r1 .F OWNER
DESCRIPTION LOT NO /L C
MAIL
BLOCK TRACTADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP �RQCESSED BY
BUILDINGS t/!/ /)
BK PG /
CONTRACTOR a7 Y's S� yl r/6,
ADORES �, CONNECTION DATA
STATIONry/r.... DEPTH
C Y L NCeloe- /O y
Q CO.
MANHOLE REFERENCE /� /��t UPR
REGISTRATION NO (� 4
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO ^O CURB P L M L TOP'
PUBLIC SEWER @ $5 00 �/ PC NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO .30 JOB NO O
PITS AND/OR DRAINFIELD @ 51000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NV
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EAS[N[xT RECORD INSTR NO DAT
WORK TO HOUSE SEWER @ $300 O
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ 55 00 {�J
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING O.
SEWER OR DISPOSAL SYSTEM @ $300 N
STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00
AUTHORIZATION I TOTAL FEE 7
CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT H THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT 7 E ABO DESC BE XISTI G DWELLING APPROVALS
TO THE PUBLIC SE DATE INSPECTORS SIGNATURE
SIGNED THIS D 1
OWNER OR ft NEW HOUSE SEWER
OWNERS AGENT r CONNECT ADDITIONAL `� v
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
I 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 ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 THE L GAL OWNER OF A INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABO ESCRI RES ENTIAL_PR TY ABANDON HOUSE SEWER
SIGNATURE �"�p BACKFILL SEPTIC TANKS ❑ a.�i
OF PERMITTEE PIT
(S)PIS) E3CESSPOOLS l'Z,1 s7/ fINU"V r
VALIDATIO ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
n�`� 5 5 7 1P 1 4 1 7 00-