HomeMy Public PortalAbout5011 BALDWIN AVE_Sewer__ 82
76A64262
APPLICATION FOR PERMIT
6A842
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS r/ t
WILLIAM A JENSEN Sup t of Building
LOCALITY 77 G i
NEAREST
FOR APPLICANT TO FILL IN CRDSS
LEGAL
DESCRIPTION LOT NO J OWNER
/ MAIL
BLOCK TRACT ^' ADDRESS �,� _
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
BK PG
CONTRACTOR
ADDRESS v CONNECTION DATA 1111
STATIONDEPTH
CITY �EL N
P y STATE MANHOLE REFERENCE p
REGISTRATION NO COUNTYS LOWE
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
gOMSE SEWER CONNECTING TO Y CURB P L ML TO P L Q.
-PUBLIC SEWER @ 55 00 O
SEPTIC TANK SEEPAGE PIT OR PO C NO
PITS AND/OR DRAINFIELD @ 31000 CO IMP NO JOB
NNO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO no
PRIVATE DISPOSAL SYSTEM @ S3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00
ALTER HOUSE HWY OR ST WIDENING
SEWER O @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ i 00 CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
1HAVE 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 INSPECTOR S SIGNATURE
SIGNED THIS DAY OF
OWNER OR
OWNERS AGENNEW HOUSE SEWER r
T_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK 1!"- p f .`� J �♦
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS 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 El ❑DRYWELL i
I HEREBY CERTIFY THAT 1 M PROPERLY REGISTERED AND/OR ALTER REF�7,zR SEWER OR
LICENSED AS REOUIR LS ANGLES COU��TATE OF S E WAGE Di S POSAir99,EMI
CALIFORNIA OR TH AM T E LEGAL OWN TEND TO DISCONNECT PLUG ANDRESIDE IN THE OVE D CRIBED RESID ABANDON HOUSE SEWER
SIGNATURE
OF PERMtTTE BACKFILL SEPTIC TANKS ❑
SEEP PIT(5) ❑ CESSPOOLS ❑
CK
0 M O CASH VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
LAAO 1 0 9 31 FEB 19 1 0 D 1 j,0 C)