HomeMy Public PortalAbout5013 BALDWIN AVE_Sewer__ _tet
CE808 10 62
78A APPLICATOON FOR PEF M11
A642D 842D
COUNTY OF LOS ANGELES SEWER—SEWAGE D POSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING / � �
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Building
LOCALITY
NEAREST
FOR APP LI A ,TO L CROSS ST '
LEGAL ,
DESCRIPTION LOT NO OWNER
MAIL�81.9C'R TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NbW ON LOT CITY 7- <-' TEL NO
USE OF
BUILDINGS DISTRICT
�(XN1/O/ GROUP BK MAP PG
J PROLES f BY
CONTRACTOR ;n;�z /J-
L
ADDRESS - l CONNECTION DATA
CITY -- e ;1 TEL STATION DEPT
C , f� H
TATE ✓ V �' PP
REGISTRATION NO '- !�� COUNTY MANHOLE REFERENCE / ' 0
NO DESCRIPTION OF WORK FEE YPE OF C(NNEC ION LENGTH OM
HOUSE SEWER CONNECTING TO Y CUR a/o./
ML TO P L
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR t,-, P C NO
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO .14)4� rO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO tJ
PRIVATE DISPOSAL SYSTEM @ $300 IILLL
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER I IASCM[MT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300 Ny
OVERFLOW SEEPAGE PIT DRAINFIELD L
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s i 00 CHARGES
AUTHORIZATION I TOTAL FEE W CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN rfAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTORS SIGNATURE
SIGNED THIS DAY O 19_
OWNER OR NEW HOUSE SEWER 4
OWNERS AGENT__
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY TH AM PROPERLY REGISTERED-AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRE BY OS ANGLES COUNTY A IT STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THA AM HE LEGAL O R D INTEND TO DISCONNECT PLUG AND
RESIDE IN THE VE SCRIBED R ENT OPERTY ABANDON HOUSE SEWER
SIGNATURE _ BACKFILL SEPTIC TANKS ❑
OF PERMITTE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
CK M O
SUPERVISING MECHANICAL ENGINEER
CASH
il
7 2 t 3 Ai?R 3 1 0 D 7 OG-