HomeMy Public PortalAbout5014 BALDWIN AVE_Sewer__ CEBDB362
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BLILDING t
JOHN A LAMBIE County Eag meet ADDRESS (/
WILLIAM A JENSEN Sup t of Buildmg n_+�-
LOCALITY (iL.(�L
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T
LEGAL
DESCRIPTION LOT NO OWNER 741
MAIL Zc��
BLOCK TRACT ADDRESS J.Y NO OF BLDGSSIZE OF LOT NOWON LOT CITY 9qTEL NOUSE OFDISTRICT NO GROUP MAP ESBUILDINGS I
� BK PG 'L
CONTRACTOR
ADDRESS a CONNECTION DATA
CITY TEL O /� STATION DEPTH
Of iy STATE MANHOLE REFERENCE UPPER
REGISTRATION NO Cry' ❑ COUNTY _
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB p M L TO P L / O
PUBLIC SEWER @ $5 00 ' /fes
SEPTIC TANK SEEPAGE PIT OR P C NO 2'.i V
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PITS AND/OR DRAINFfELD @ $1000 CO IMP NO JOB NO �
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO O
PRIVATE DISPOSAL SYSTEM @ $3 00 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500 HWY OR ST WIDENING L
ALTER REPAIR OR ABANDON HOUSE .�
SEWER OR DISPOSAL SYSTEM 1300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ z o0 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTORS SIG7ATUl E
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
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 IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS 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 DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PITS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
LAlo7306' NOV 2310D 7a0
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