HomeMy Public PortalAbout5015 BALDWIN AVE_Sewer__ PF
62
76A64262
APPLICATION FOR PERM � >
6A842
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION M BUILDING
JOHN A LAMBIE County Engineer ADDRES^ 01/. gE..Y
WILLIAM A JENSEN Sup t of BuildingLOCALITYNEARESTFOR APPLICANT TO FILL IN CROSSSLEGALDESCRIPTION LOT NO OWNER
MAILBLOCK TRACT ADDRESSNO OF BL GS
SIZE OF LOT NOWON LOT CITY TEL NO
USEOFDISTRICT NO GROUP MAP PRO
BUILDINGS
CONTRACTORf,/ BK PG `
ADDRESs� �++7CONNECTION DATA
CITY TE STATION `' ^ DEPTH
REGISTRATION NO ❑ STATE MANHOLE REFERENCE UPPER
❑ COUNTY ) l�
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO CURB P L M L TO P L
PUBLIC SEWER @ $5 00 P C NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO U
PITS AND/OR DRAINFIELD @ E1000Itla
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $3 00 [�
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ S300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE a $500 HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $1 21 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO COV NECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
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 ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRE LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH A THE LEGAL OWNE F AND I TEND TO DISCONNECT PLUG AND
RESIDE IN THE VE ESCRI BED RESIDE
AL P OP TY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PER MITT SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
M O CASH SUPERVISING MECHANICAL ENGINEER
CK
LACO 1 0 9 410 FEB 19 1 0 D 7,V 0 civ