HomeMy Public PortalAbout5109 BALDWIN AVE_Sewer__ J
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76A 642D APPLICATION FOR PERM 1 .�
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
J0H\ A LANIRIN County h ngtnecr ADORE
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C01 I MAN R JF NKINA Sup t of Ruildtt
LOCAL TY
NEAREST
FOR APPLICANT TO FILL `Ross BT
LEGAL
DESCRIPTION LOT NOOWNER
MAIL
BLOCK TRACT +0- ADDRESS
O OF SLOGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP BK MAP PRpp�CESSE0 BY
BUILDINGS
CONTRACTOR
,@ L P�v
ADDRESS .,.G� CONNECTION DATA
,^ STATION DEPTH
CI Y TEL NO /�'
LICE NS LICENSE -2' J (JiiGifi
NO 7Q/ CLASS MANHOLE REFERENCE
LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM J
HOUSE SEWER CONNECTING TO CURB PL ML
PUBLIC SEWER C $ 5 00
PTI ANTI EE AGE PIT OR Q PC NO CL
PITS AND/OR DRAINFIELD C $1 0 00 CO IMP NO @ .108 NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT V
PRIVATE DISPOSAL SYSTEM C $ 3 00 (�
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wnIYER EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER C $ 3 00
R OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM C $ 3 00 W
HWY OR ST WIDENING a
EXTN CESSPOOL MAN OLE @ $ 5 00 h
STATE ENCROACHMENT Z
PERCOLATION TEST @ $ 5 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S z 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE �
I HAVE AT THIS DATE A CONTRACT WI H THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNEC THE ABOVE DE CR ED EXISTING DWELLI
TO THE PUBLIC SEW APPROVALS DATE INSPE OR S SIGNATURE
SIGNED THIS D 1 >
OWNER OR NEW HOUSE SEWER i
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HFREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
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 REQUIRE Y LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT/,A THE LEGAL OWNER OF NO INTEND TO DISCONNECT PLUG AND
RESIDE IN THE AS DESC ED R SIDE NTAIAL OPERTY ABANDON HOUSE SEWER
SIGNATURE
APERMITTEE 4 BACKFILL SEPTIC TANKS ❑
SEEP PIT(S) ❑ CESSPOOLS
VALIDATIO
CK M O CASH
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