HomeMy Public PortalAbout5033 BALDWIN AVE_Sewer__ CESOB 3-62 APPLICATION FOR PERMIT.
76A642D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING y��
JOHN A. LAMBIE, County Engineer ADDRESS SV/
WILLIAM A. JENSEN. Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL 6:e,
DESCRIPTION LOT NO. OWNER
MAILBLOCK TRACT ADDRESS
NO. OF SLOGS. T
SIZE OF LOT NOW ON LOT CITY / • TEL. NO.
USE 01F NGS DISTRICT NO. RO MAP PROCESSED BY
BK PG
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CONTRACTOR .�
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ADDRESS CON EC I N DATA
CITY TE STATION DEPTH
�IISTATE MANHOLE REFERENCE
REGISTRATION NO. ElCOUNTY ' LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CON NECTI N NGTH F M
HOUSE SEWER CONNECTING TO &0 Y. CURB P.L. M.L.TO P. Q
PUBLIC SEWER @ $5.00 `5 V v P.C.NO.
SEPTIC TANK,SEEPAGE PIT PR
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. O JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. y
PRIVATE DISPOSAL SYSTEM @ $3.00 IV ..�
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAER EASEMENT RECORD.INSTR,NO. BATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
E XTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR 57.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
. 7 W
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN MED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR' SIGNA. URE
SIGNED THIS DAY OF ig_ CONNECT ADDITOWNER OR NEW HOUSE SEWER °
OWNERS AGENT_
IONAL
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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUI D 'LOS ZwL
OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH I HE D TODISCONNECT PLUG AND
RESIDE IN, THE A V SCRIBEABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PITS) ❑ CESSPOOLS ❑
100, VALIDATION ROBERT A. WOOD
CK. M.O.
SUPERVISING MECHANICAL ENGINEER
CASH '] I�^} 7
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