HomeMy Public PortalAbout5031 BALDWIN AVE_Sewer__ 76AG42D 61 APPLICATION FOR PERMIT
76A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESS,
NG
JOHN A LAMBIE County Engineer
WILLIAM A JENSEN Sup t of Building ITYST
FOR APPLICANT TO FILL IN CRo55 9T
LEGAL
DESCRIPTION LOT NO OWNER
MAIL /BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT / CITY 7-4--, TEL NO
USE OF
BUILDINGS DISTRICT NO GROU MAP PROCESSED BY
f �CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL N ST&N DEPTH
Er S ATE MANHOLE REFERENCE
REGISTRATION NO ❑ COUNTY LOWER
NO DESCRIPTION OF WORK FEE P!; ON ON LE H FROM
HOUSE SEWER CONNECTING TO Y IL TO P L
PUBLIC SEWER @ S5 00
PC NO
SEPTIC TANK SEEPAGE PIT OR
PITS ANDOR DRAINFIELD @ $1000 CO IMP NO 3 JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO i+
PRIVATE DISPOSAL SYSTEM @ $300 (f
CONNECTADDITIONAL BLDG OR AFFIDAVIT WAIVER I EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER O SPOSAL SYX9rEM @ S3 00 STATE ENCROACHMENT 6•
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER S PERMIT $ CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE 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 tg_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT__ CONNECTADDITIONAL
ADDRESS
/ BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY TH I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REOU R Y LOS ANGLES OUNTY A D STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T I M THE LEGAL ER OF A INTEND TO DISCONNECT PLUG AND
RESIDE IN THE O DESCRIBED R D TIAL R ERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMfT ' SEEP BACKFILL
PIT(SEP❑ TANKS E]
❑
VALIDATIOY—--., ROBERT A WOOD
CK M O C/ SUPERVISING MECHANICAL ENGINEER
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76A642D APPLICA ION FOR ERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING jrD.Y
JOHN A LAMBIE County Engineer ADDRESSWILLIAM A JENSEN Sup t of Building
LOCALITY 77
NEAREST
FOR APPLIC TO FILL IN CROSSLEGAL
DESCRIPTION LOT NO OWNER
MAIL �OBLOCK TRACT ADDRESSNO OF BLDGSSIZE OF LOT NOWON LOT CITY s TEL NO
USE OFBUILDINGS DISTRICT NO GR MAP PRO
BK PG
CONTRACTOR14 v !�,
ADDRE�y e , — CONNECTION DATA
CITY TEL ON DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO ❑ COUNTY LOWER
NO DESCRIPTION OF WORK FEEPE OF N T N LE GTH FR
HOUSE SEWER CONNECTING TO iQ y� Y5gl p M L TOP L / O
PUBLIC SEWER @ $5 00 (/—(/
SEPTIC TANK SEEPAGE PIT OR P C NO
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO /y V
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $3 00 TRUNK PERMIT NO ROAD PERMIT NO �y / O
Il
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER E11EMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500 N
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING L_
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
WNER S PERMIT s z 00 CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTORSIG AT RE
SIGNED THIS DAY OF fig_
OWNER OR NEW HOUSE SEWER "
OWNERS AGENT_
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PIT(S)
1 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 ElPLUMBING AND SEWERS CESSPOOL [I DRYWELL
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I E LEGAL OW OF AND NTEND TO DISCONNECT PLUG AND
LLOFIERMITTEE
IN THE AB D LRIBED REST IAL P OP TY ABANDON HOUSE SEWER
URE
' SAC FIPIT(S)LPTIC TANKS
❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
CK M O
SUPERVISING MECHANICAL ENGINEER
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