HomeMy Public PortalAbout5016 BALDWIN AVE_Sewer__ (2) GEBOB3 82
78A842D APPLICATION FOR PERMI
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING r/��
JOHN A LAMBIE County Enggmeer ADDRESS /�
WILLIAM A JENSEN Supt of Buwldwg
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY ( TEL NO
USE OF
BUILDINGS DISTRICT NO G P BK MAP d PROCESS D BY
CONTRACTOR
ADDRESS �CLY/ti CONNECTI ATA -�
s
CITY TEL N
STATION l DEPTH
`.J
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO / ❑ COUNTY
1
NO DESCRIPTION OF WORK FEETYPE OF CO NNECTIO LENGTH OM
HOUSE SEWER CONNECTING TO moi' Y CURB P L M L TOP
PUBLIC SEWER @ $5 00 (l p C NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO U
PITS AND/OR DRAINFIELD @ S1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO a'
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE $5 00 HWY OR ST WIDENING 7
ALTER REPAIR OR ABANDON HOUSE b
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ i 00 CHARGES
AUTHORIZATION TOTAL FEE 2 1
CONNECTION CHARGE FEE
ITHAVE AT THIS DATE A CONTRACT WIH THE HEREIN AMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS D TE INSPECTOR S SIG�N� URE
SIGNED THIS DAY OF 19_ �-
OWNER OR NEW HOUSE SEWER d
OWNERS AGENT_
CONNECT ADDITIONAL ✓�
ADDRESS BUILDING OR WORK
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 ❑
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
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE E;,E DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE j BACKFILL SEPTIC TANKS ❑
OF PER MTTTEE SEEP PIT(5) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
CK M o ASH SUPERVISING MECHANICAL ENGINEER
4
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