HomeMy Public PortalAbout5522 BALDWIN AVE_Sewer__ (2) 808 1 �
CE 642D0 63 APPLICATION FOR PERMIT
11 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 11
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDINGS w.
WIOHN A. LAMBIE, County EDQinBB! ADDRESS �(,C
LLIAM A+ JENSEN, Supt of Building
LOCALITY
_mINEAREST 011
FOR APPLICANT TO FILL IN CRDss sT.
LEGAL
DESCRIPTION LOT NO. OWNER
er� MAIL
BLOCK TRACT SC/ � ADDRESS
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PIROCESSED 9Y
PG
CONTRALTO
ADDRESS �d .CONNECTION DATA
CITY NO. STATION 5"A J DEPTH ^ '
REGISTRATION NO. COUNTY STATE MANHOLE_REFERENCE ("�� ! r' LOWER
ii NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO CURBP.L M.L.TO P.L.
PUBLIC SEWER $5.00 P.C.NO. ' % O
CO.IMP.NO.
SEPTIC TANK,SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 V
HOUSE SEWER CONNECTING TO TRUNK'PERMIT NO. ROAD PERMIT NO. OL
PRIVATE DISPOSAL SYSTEM $8.00 ,, O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EARERENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $8.00
OVERFLOW SEEPAGE PIT,DRAINFIELD LU
EXTN..CESSPOOL,DRYWELL.MAN H OLE @ 55.00 d
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING H
SEWER OR DISPOSAL SYSTEM 59.00 `
STATE ENCROACHMENT 410
h
PERMIT NO. V
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
-1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIM BU RSEMENT,FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED'THIS DAY OF l9_
OWNER OR NEW-HOUSE SEWER �a
OWNERS AGENT CONNECT ADDITIONAL IV
BUILDING OR WORK '
ADDRESS
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PITS)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD.
WITH. ALL COUNTY ORDINANCES AND STATE LAWS
PLUMBING AND SEWERS. - SSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTEAND/ORLTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. ANISCONNECT PLUG AND
RESIDE IN, THE A OVE DES ISED REST NTIAL Raj
BANDONHOUSESEWER
SIGNATURE CKFILL SEPTIC TANKS ❑TTE EP.•PITYS) ❑ .CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
cK. M.o, cpsH SUPERVISING MECHANICAL ENGINEER
L&",-3 '6. 6 0.10 14AR20 1 0 D- .5.00~ v