HomeMy Public PortalAbout5019 BALDWIN AVE_Sewer__ (2) 6A642D 62
7 ,APPLICATION FOR PE MIT
6A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
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JOHN A LAMBIE County Engineer
WILLIAM A JENSEN Sup t of Building c
LOCALITY i
if NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NOf OF BLDGS
SIZE OF LOT NOW ON LOT CITY t TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
BK PG
CONTRACTOR /—3� )4LZ—�.
ADDRES ?� 6;?,e (� C///ONNECTION DATA
CITY TEL _77Z
STATION / If DEPTH
REGISTRATION NO STATE MANHOLE REFERENCE G-�'� UPPER /
1 �+� �v .L-� El COUNTY
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM }
1 HOUSE SEWER CONNECTING TO ^� CURB P L ML TO P L g
PUBLIC SEWER @ $5 00 P CNO.10B NO
v
SEPTIC TANK SEEPAGE PIT OR J V
PITS AND/OR DRAINFIELD C $1000 CO IMP NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $300 TRUNK PERMIT NO ROAD PERMIT NO }}0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER I EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING _
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
��'
WASTE APPROVAL
OWNER'S NER'S PERMTT $ 2 00 CHARGES
AU'T'HORIZATION TOTAL FEE II CONNECTION CHARGE FEE
I HAVE 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/ INSPECTOR S SIG 1A{URE
SIGNED THIS DAY OF )g_ j� Ii..'.-._.
OWNER OR ,//,//_ NEW HOUSE SEWER
OWNERS AGENT L//�.� ��" f 5i ��lk�
CONNECT ADDITIONAL
ADDRESS
1 BUILDING OR WORK
SEPTIC TANKSEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAI NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY TH I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUI LOS ANGLES OUNTY AN STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T I THE LEGAL ER OF AN INTEND TO DISCONNECT PLUG AND
RESIDE IN THE O DESCRIBED R ENTIA PR ERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMIT J BACKFILL SEPTIC TANKS ❑
SEEP PIT(5) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
CK M o CASH SUPERVISING MECHANICAL ENGINEER
1 0 9 6'." FEB 19 1 0 D 7,0 J-
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