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Home My Public Portal About5031 BALDWIN AVE_Sewer__ (2) 76AG42D 61 APPLICATION FOR PERMIT 76A642 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FADDRESS, NG JOHN A LAMBIE County Engineer WILLIAM A JENSEN Sup t of Building ITYST FOR APPLICANT TO FILL IN CRo55 9T LEGAL DESCRIPTION LOT NO OWNER MAIL /BLOCK TRACT ADDRESS NO OF BLDGS SIZE OF LOT NOW ON LOT / CITY 7-4--, TEL NO USE OF BUILDINGS DISTRICT NO GROU MAP PROCESSED BY f �CONTRACTOR ADDRESS CONNECTION DATA CITY TEL N ST&N DEPTH Er S ATE MANHOLE REFERENCE REGISTRATION NO ❑ COUNTY LOWER NO DESCRIPTION OF WORK FEE P!; ON ON LE H FROM HOUSE SEWER CONNECTING TO Y IL TO P L PUBLIC SEWER @ S5 00 PC NO SEPTIC TANK SEEPAGE PIT OR PITS ANDOR DRAINFIELD @ $1000 CO IMP NO 3 JOB NO V HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO i+ PRIVATE DISPOSAL SYSTEM @ $300 (f CONNECTADDITIONAL BLDG OR AFFIDAVIT WAIVER I EASEMENT RECORD INSTR NO DATE WORK TO HOUSE SEWER @ $300 OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE @ $500 ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING SEWER O SPOSAL SYX9rEM @ S3 00 STATE ENCROACHMENT 6• PERMIT NO INDUSTRIAL WASTE APPROVAL OWNER S PERMIT $ CHARGES AUTHORIZATION TOTAL FEE 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 SIGNATURE SIGNED THIS DAY OF tg_ OWNER OR NEW HOUSE SEWER OWNERS AGENT__ CONNECTADDITIONAL ADDRESS / BUILDING OR WORK I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S) AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD WITH ALL 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 REOU R Y LOS ANGLES OUNTY A D STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR T I M THE LEGAL ER OF A INTEND TO DISCONNECT PLUG AND RESIDE IN THE O DESCRIBED R D TIAL R ERTY ABANDON HOUSE SEWER SIGNATURE OF PERMfT ' SEEP BACKFILL PIT(SEP❑ TANKS E] ❑ VALIDATIOY—--., ROBERT A WOOD CK M O C/ SUPERVISING MECHANICAL ENGINEER /cASH Ltll04 2 4 22 IAY 3 1 J D 2500 �' b nml� 82� 76A642D APPLICA ION FOR ERMIT 6A642 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING jrD.Y JOHN A LAMBIE County Engineer ADDRESSWILLIAM A JENSEN Sup t of Building LOCALITY 77 NEAREST FOR APPLIC TO FILL IN CROSSLEGAL DESCRIPTION LOT NO OWNER MAIL �OBLOCK TRACT ADDRESSNO OF BLDGSSIZE OF LOT NOWON LOT CITY s TEL NO USE OFBUILDINGS DISTRICT NO GR MAP PRO BK PG CONTRACTOR14 v !�, ADDRE�y e , — CONNECTION DATA CITY TEL ON DEPTH STATE MANHOLE REFERENCE REGISTRATION NO ❑ COUNTY LOWER NO DESCRIPTION OF WORK FEEPE OF N T N LE GTH FR HOUSE SEWER CONNECTING TO iQ y� Y5gl p M L TOP L / O PUBLIC SEWER @ $5 00 (/—(/ SEPTIC TANK SEEPAGE PIT OR P C NO PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO /y V HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM @ $3 00 TRUNK PERMIT NO ROAD PERMIT NO �y / O Il CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER E11EMENT RECORD INSTR NO DATE WORK TO HOUSE SEWER @ $300 OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE @ $500 N ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING L_ SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL WNER S PERMIT s z 00 CHARGES AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER APPROVALS DATE INSPECTORSIG AT RE SIGNED THIS DAY OF fig_ OWNER OR NEW HOUSE SEWER " OWNERS AGENT_ CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK SEEP 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 WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING ElPLUMBING AND SEWERS CESSPOOL [I DRYWELL IHEREBY 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 I E LEGAL OW OF AND NTEND TO DISCONNECT PLUG AND LLOFIERMITTEE IN THE AB D LRIBED REST IAL P OP TY ABANDON HOUSE SEWER URE ' SAC FIPIT(S)LPTIC TANKS ❑ CESSPOOLS ❑ VALIDATION ROBERT A WOOD CK M O SUPERVISING MECHANICAL ENGINEER ASH t_f(L,o 'd 2 4 1 03 I IPY 3 1 0 D 7 ")0 Y