HomeMy Public PortalAbout4837 BALDWIN AVE_Sewer__ 1 :E /mFL G1 ry-
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76A642D APPLICATION FOR PERMIT
78A84
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Building C-0
LOCALITY
NEAREST
LICANT TO FILL IN `Ross ST
L
NO OWNER
MAIL G /
TRACT � ADDRESS
O OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
C //�
CONTRACTOR 07 15– F,5;—
V C I—Dv KV
ADDRESS 9 7-- CONNECTION DATA
CITY TEL N004,0 6(} 7 STATION r S 0 DEPTH
❑ STATE MANHOLE REFERENCE 565
REGISTRATION NOAx E) COUNTY LOWER d
NO DESCRIPTION OF WORK fFEE TYPE OF CONNECTION LENGTH FROM O
HOUSE SEWER CONNECTING TO r p c CURB P L ML TO P L U
PUBLIC SEWER C�4 E3 00 S ��
SEPTIC TANK SEEPAGE PIT OR ' �` J C NO OC
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO �D3 JOB NO y`0
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT N V
PRIVATE DISPOSAL SYSTEM @ $300 lJJ
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER I EASEMENT RECORD INSTR NO DATE n'
WORK TO HOUSE SEWER @ $300 N
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ s 00 CHARGES
�� CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE/f t INSPECTQOR S SIGN �rURE
SIGNED THIS DAY OF 19_
OWNER ORAGENT �j NEW HOUSE SEWER
OWNERS
p CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
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 ❑
1-HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOV D SCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION^ ROBERT A WOOD
CK M O H
"-'H SUPERVISING MECHANICAL ENGINEER
� 0 5 i z 6 j,'1 IN 1 r p 7 ;'ON 5,1