HomeMy Public PortalAbout5437 BALDWIN AVE_Sewer__ (2) 7SAO.2D
CESD aso APPLICATION F R PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DMSION BUILDING 3
ADDRESS
OHN A LAMBIE Couatp Ea eer
C AIT D GRIFFIN Sup! of Bsuld�ng LOCALITY
NEAREST
FOR APPLICANT TO FELL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRAC MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT J CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP APE#E BY
BK PG
CONTRACTOR
ADDRESS g' CONNECTIONDATA
CITY TEL NO ION l DEPTH
STATE MANHOLE REFERS CE
REGISTRATION NO ® COUNTY aye -3r
No DESCRIPTION OF WORK FEE
PUBLICSEWWEERCONNECTING TO @ $3 00 yS &
TYPE OF CONNECTIO LENGTH FROMSEPTIC TANK �'
PITS AND/OR DRAINFIELD $3 OR @ S3 00 Y CURB P L M L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ 31 00
ALTER
ER OR DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTEAPPROVAL
CHARGES
OWNEh S PERMIT S CONNECTION CHARGE FEE -/V
AUTHORIZATION TOTAL FEE f!`rti REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE I SPEQTORSSy�NATUR
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER n
OWNER OR /7/1 CONNECT ADDITIONAL
OWNERS AGENT ' ' / BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION pp
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ ` I1��
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS t SEWAGE DISPOSAL SYSTEM
IHEREBY 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 BACKFILL SEPTIC TANKS ❑
DESCRIBED RESIDE TIAL PROPERTY SEE PITS ❑ CESSPOOLS ❑
SIGNATURE
OF PERMITTE
OF VALIDATION ROBERT A WOOD
CK m o CASH SUPERVISING MECHANICAL ENGINEER
(� -02831) JU,1 2 7 1 1 D 2 5 () 0
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CEBOB� _D9 .�- APPLICATION F PERMIT
Cfi �'� 7
COUNTY OF LOS ANGELES SEWER—SEWAGED SPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DMSION BUILDING }� li/ d�,
gsn ADDRESS , J A
C IASSAIT D GRIFFIN SupLAMIE t t of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL ���77����
DESCRIPTION LOT NO OWNER " �� E
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE
BUILDINGS BK P6 DISTRICT NO GROUP MAP ppppOCESSE Y
CONTRACTOR �� T
ADDRESS / CONNECTION DATA
CITY TEL NO T N DEPTH V
B STATE ANHO E REFERENC PPE
REGISTRATION NO COUNTY a
NoTI NOF WORK FEE J ,� /r�
HOUSESEDESCRIPTION
SEWER CONNECTING TO �(/�" �+
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L14 M L TOP L
PITS AND/OR DRAINFIELD @ $e 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TOP C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1 00
SALTER EWER OR AIROR O AABANDON
SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT 5=21 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
DAA CONTRACT WITH THE HEREINAMED CON
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNAT RE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR /1/1 CONNECT ADDITIONAL
OWNERS AGENTr< 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
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 BACKFILL SEPTIC TANKS ❑
DESCRIBED RESIDEN I PROPERTY
SIGNATURE SE PITS) ❑ C SPOOLS ❑
OF PERMITTE
OF VALIDATION ROBERT A WOOD
C6 X O GASB l SUPERVISING MECHANICAL, ENGINEER
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