HomeMy Public PortalAbout5424 BALDWIN AVE_Sewer__ (2) C
!�'Z— 2465_INS J
CEBOB880
78A842D APPLICATION FOR PERMIT -
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER � rr _
BUILDING AND SAFETY DIVISION ADDRESS BUILDING —? '
OIiN A
LAME County Engineer
A IENSEN Sup t of Building LOCALITY
NEAREST
FOR APPLICANTTO CROSS ST
LEGAL OWNER
DESCRIPTION LOT NO
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE DI DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
/ BK PG
CONTRACTOR 5-1"
0�— /
ADDRESS ''— CONNECTION DATA
CITY TEL NO ��J STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO P COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Co) $3 00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PTS AND/ORDRAIN FIELDT OR @ $3 00 Y CURB P L M L TO P L
-
OVERFLOW SEEPAGE PIT DRAINFIELD 4
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $100 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ' ROAD PERMIT NO V
WORK TO HOUSE SEWER @ $1 00
SEWER OR DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT Al
PERMIT NO M
INDUSTRIAL U
WASTE APPROVAL w
CHARGES W
OWNERS PERMIT E 2 00 CONNECTION CHARGE FEE _
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE. INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER /
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL v '�
OWNERS AGENT _ BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS ❑
SIGNATURE - SEEP PITS ❑ CESSPOOLS ❑ _ ( �"1
OF PERMITTE
®� VALIDATION ROBERT A WOOD
CK m o cases SUPERVISING MECHANICAL ENGINEER
LAS: 0 8 9 0 1_13 At,
� t; p 500 U