HomeMy Public PortalAbout5452 BALDWIN AVE_Sewer__ (2) C�
6A64 2D 3 64
7APPLICATION FOR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING r
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t o4 Building
LOCALITY
NEAREST !
FCRIPTION
R APPLICANT TO FII.L IN [CROSS ST
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LOT NO J OWNER
MAIL
TRACT ADDRESS
NO OF SLOGSNOW ON LOT CITY TEL NO
DISTRICT NO GR UP MAP PROCESSED BY
BUILDINGS
L BK PG
CONTRACTO ,./
ADDRESS / J` /
CONNECTION'DATA
CITY '44EL NO 3 Q�d STATION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO COUNTY Q r a_ LOWER
NO DESCRIPTION OF WOR FEE TYPE OF CONNECTION LENGTH F M
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP
PUBLIC SEWER $5 00 PC NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO �.
PITS AND/OR DRAINFIELD @ $1000 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO U
PRIVATE DISPOSAL SYSTEM @ S3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER 1A11M[NT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300 O
OVERFLOW SEEPAGE PIT DRAINFIELD - V
EXTN CESSPOOL DRYWELL MANHOLE @ $500
ABANDON HOUSE HWY OR ST WIDENING W
SEWER SYSTEM E3 00 G � d
STATE ENCROACHMENT /� N
PERMIT NO ,� (/ Z
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT S 2 00 CH GES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESC D EXISTING DWELLING APPROVALS
TO THE PUBLIC SE ER �^ DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ T IS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL S YSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE
ECRIBED RESIDENTIAL PROPP RT
ABANDON HOUSE SEWER Y r
SIGNATURE �2
BACKFILL SEPTIC TANKS ❑
OF PERMITTE_ ❑
SEEP PIT(S) El CESSPOOLS
VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
7JKM O CASH
J 6 7 1 1. �� 16 1 0 5.�0� e