HomeMy Public PortalAbout4916 1/2 BALDWIN AVE_Sewer__ YA"-
76A6642D6t APPLICATION FOR PERMIT l/
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUJLDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE County Engineer ADDRESS
IA
WILLM A JENSEN Sup t of Building_ LOCALITY
NEAREST
FOR APPLICANT TO FILL IN ceoss ST
LEGAL OWNER / V C D
DESCRIPTION LOT NO
BLOCK TRACT NAIL ADDRESS ! JBY J
N F BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP P ESS
BUILDINGS
BK P3
CONTRACTOR C dL
ADDRESS dJ pp CONNECTION DATA
CITYTEL N {p �j s ST ON DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO COUNTY / LOWER
No I DESCRIPTION OF _ FEE
HOUSE SEWER CONNECTING TO y /
PUBLIC SEWER @ ADD TYPE OF CONN TION 1 LENGTH FROM
PETS AND/OR DRAINFGPTIC TANK ELDT OR @ $ 00 Y C w M L TO P L
OVERFLOW SEEPAGE PIT DRAINVIELD J L
EXTN CESSPOOL DRYWELL @ S 00 IL
HOUSE SEWER CONNECTING TO P C NO O
PRIVATE DISPOSAL SYSTEM @ S 00 CO MP NO JOB NO U
CONNECT ADDITIONAL BLDG OR -- TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER@ S 00 O
SEWER OR PAIRO R ABANDON HOUSE @ 00 STATE ENCROACHMENT
PERMIT NO U
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INDUSTRIAL d
WASTE APPROVAL
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OWNER S PERMIT 51 2 00 ) CONNECTION CHARGE FEE
TH
AUORIZATION TOTAL FEE U 1 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 `D Y OF y9— NEW HOUSE SEWER
OWNER OR i/��a CONNECT ADDITIONAL "�tr/
OWNERS AGENT r - BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AHD/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT f HAVE REVD 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 SYSTE14
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 A10 THE LEGAL WNER OF THE ABOVE
DESCRIBED RESIDENT+ P PERTY BACKFILL SEPTIC ANftERT
SEEP PIT( CESSIGNATUREOF PERMITTE 9,VAUDATION A WOOD
Y 0 use SUPERVISING MECHANICAL ENGINEER
Lk0 9 4 1 2 "a MAR 91 OD 600 `�
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76A64261
APPLICATION FOR PERMIT'
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDQq y ��
JOHN A LAMBIE County En eer ADDRESINS
WILLIAM A JENSEN Supt of Building_ LOCALITY
NEAREST
FADDRESS
OR APPLICANT TO FILL IN CROSS ST
0
ON LOT NO OWNER
TRACT MAIL
ADDRESS'T L V
NO F BLOGS
T NOW ON LOT CITY' TEL NO
DISTRICT NO GROUP MAP PROCESSED BY
OF
S BK P8
OR l
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CONNECTION DATA TEL NO 6 7ATION DEPTH
STATEMANHOLE REFERENCE
REGISTRATION NO COUNTY LOWER
NO I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $S 00 TYP B CON C LENGTH FROM /
PETPTIC TANK S AND/OR SEEPAGELDT OR @ 53 00 Y CL M L TOP L 7
OVERFLOW SEEPAGE PIT DRAINFIELD 1'
EXTN CESSPOOL DRYWELL @ $2 00 Ii
HOUSE SEWER CONNECTING TO 7 P C NO 0
PRIVATE DISPOSAL SYSTEM @ St 00 CO IMP NO J JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NOEZ
WORK TO HOUSE SEWER @ $1 00 0
SEWER OR DIISPOSAL ABANDON HOUSE $I 00 STATE ENCROACHMENT F
PERMIT NO U
INDUSTRIAL
WASTE APPROVAL N
CHARGES Z
OWNER$ PERMIT ICONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE O REIMBURSEMENT FEE
IHAVE AT THIS CON
TRACTOR TO CONNECT THE ABOVE A CONTRACT DESCRIBED EXIISTINGAMED DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF ISI— NEW HOUSE SEWER
OWNER OR 1 ^f CONNECT ADDITIONAL
OWNERS AGENT v — BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
LCDESCRIBEI
EBY ACKNOWLEDGE THAT I. HAVE READ THIS APPLICATION
TE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
LL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
G AND SEWERS SEWAGE DISPOSAL SYSTE
I
EBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
D AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
NIA OR THAT AM THE LEGAL OWNER OF THE ABOVE
ED RESIDEN IA PROPERTY BACKFILL SEPTIC TANKSRESEEP PIT(S CESSPOOLS
MITTE L,
AMATION ROBERT A WOOD
t( 6 J x 0 GSR SUPERVISING MECHANICAL ENGINEER
LACo 9 4 1 3 -0 MAR 9 1 1 D 2 5 0 0
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