HomeMy Public PortalAbout5231 BALDWIN AVE_Sewer__ (2) 24650 INSERTS `
7SA642D60 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DMSION ADDRESSG
JOHN A LAMBIE County Enggweer
WILLIAM A JENSEN Supt of Budding LOCALITY
NEAREST
FOR APPLICANT TO FILL IN caoss sr
LEGAL
DESCRIPTION LOT NO
OWNER ce +
BLOCK TRACT /`. MAIL
ADDRESS
NO OFBLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO I GROU MAP PROCESSED BY
rPG
Ex-
CONTRACT r 1j
ADDRESS 4 A. CONNECTION DATA
CITY- TELNO G STATION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION N0- IF COUNTY i `22. C LOWER
NO I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOQ
PUBLIC SEWER @ $3 00 TYPE OF CONNECTIO L TH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB �P L M TOP L
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 c0 IMP No i JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO a
WORK TO HOUSE SEWER @ $1 00 /� V
ALTER REPAIR OR ABANDONHOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYST M @ $100
PERMIT NO
INDUSTRIAL
WASTE APPROVAL W
CHARGES al V
OWNERS PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE e-40 REIMBURSEMENT FEE
CON
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIISTINGDATE A CONTRACT WITH THE HEREINAMED DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT-Z-8. - BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM IV
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND I I f
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER t /
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE t
DESCRIBED RESID AL PROPERTY BACKFILL SEPTIC TANKS
SIGNATURE SEEP PIT(S) CESSPOO❑LS ❑
OF PERMITTE
IW�l Ta
OF VALIDATION ROBERT A WOOD
IL
Cm o CASH SUPERVISING MECHANICAL ENGINEER
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