HomeMy Public PortalAbout5026 BALDWIN AVE_Sewer__ c�
76A 642D-CE808-10-71 APPLICATION FOR 1PIRMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING )
ADDRESS l
LOCALITY �-
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT .. '3 OZvi ADDRESS ~ �'
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY J67.L. NO.
USE OF DISTRICTN0. GROUP BK MAP Po SSED BY
BUILDINGS
60NTRACTOR,44P iO0 L //'J 3 /G'�
ADDRESS CONNECTION DATA [�`
CITY ! TEL. NO STATION DEPTH
STAT LIC MANHOLE REFERENCE UPPER
LICENSE NO. CLASS LOWER
NO. I DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FROM
HOUSE SEWER CONNECTING TO �� Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER $7.00
SEPTIC TANK.SEEPAGE PIT OR P.G.NO.
PITS AND/OR DRAINFIELD $10.00 CO.IMP.NO. .108 NO. ������//////
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N1,o /
PRIVATE DISPOSAL SYSTEM @ $3.00 VV G
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVE• EASEMENT RECORD.INSTR.NO. DATE O
0
WORK TO HOUSE SEWER Q $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD Q'
EXTN..CESSPOOL.DRYWELL. a $5.00 O
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENIN
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMEN W
MANHOLE ! $7.00 PERMIT _ G.
IND TRIAL I v f(f Z
WAST E APPROVAL 7TF1 f'
r:� CHAR ;e •
OWNERS PERMIT s 3 00 _ �� E 'a
Irl
- N
AUTHORIZATION TOTAL FEE CONCT
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMRSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. ALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY 19_
OWNER OR _ / NEW HOUSE SEWER / I
OWNERS AGENT ov
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS 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
LRESIDE
COUNTY ORDINANCES AND STATE LAWS REGULATING
AND SEWERS. CESSPOOL ❑ DRYWELL ❑
Y CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
A OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
, T ABOVE DESCRIBED RESIDEN� PROPERTY. ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑ ❑
SEEP.PIT(S) ❑ CESSPOOLS
VALIDATION CK, M.0. CASH
9 etiF G cb 1 u D 1 A c