HomeMy Public PortalAbout5412 BALDWIN AVE_Sewer__ 76A 642D CE808 A 7/76 I
APPLICATION FOR PERMIT lul
SEWER—SEWAGE DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGFOR APPLICANT TO FILL IN
IN _SK(� P
ADDRESS /2 L YI/// - �� J/ I 1 l /J���
CONNECTION DATA
LOCALITY
NEAREST C STATION DEPTH
CROSS ST O L / („, UPPER
OWNER /L. GO /C ��/��/� MANHOLE REFERENCE
t
TYPE OF CONNECTION LENGTH FROM LOWER
MAIL d] I1 O �'/ Y CURB P L M L TOP L
ADDRESS �1 �V /` PC NO
ry
CITY S -17 CO IMP NO JOB NO
/ TEL NO V
LEGAL TRUNK PERMIT NO ROAD PERMIT NO
DESC R II PTION LCT f g
/ AFFIDAVIT I wAIV[R [,mm, RECORD INSTR NO F DATE
BLOCK TRACT
NO OF BLDGS
SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
I
USE OF STATE ENCROACHMENT
BUILDINGS PERMIT NO 1)
t
INDUSTRIAL
CONTRACTOR WASTE APPROVAL 0.
ADDRESS CHARGES G
V
CONNECTION CHARGE FEE
CITY TEL NO O
STATE LIC REIMBURSEMENT FEE
LICENSL NO CLASS
NO DESCRIPTION OF WORK FEE --APPROVALS DATE INSPECTOR S SIGNATURE i5
NO
HOUSE SEWER CONNECTING TO a
PUBLIC SEWER I N
NEW HOUSE SEWER
SEPTIC FANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK �J A
PRIVATE DISPOSAL SYSTEM SEPTIC TANKSEEP PIT(S)
CONNECT ADDITIONAL BLDG OR AND/OR DRAT NFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT DRAINFIELD CESSPOOL ❑ DRYWELL ❑
EXTN CESSPOOL DRYWELL MANHOLE
00
ALTER REPAIR SEWER OR
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM ® SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BA�PITS)
TICT
TANKS ❑
SE ❑ CESSPOOLS ❑
OWNERS Issuance Fee s OD
��[[ I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AUTHORIZATION TOTAL FEE VCS AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON PLUMBING AND SEWERS
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I HEREBY CERTIFY THAT I AM PROPERLY REGISTER(D D/OR
TO THE PUBLIC SEWER LICENSED AS REQUIRED BY LOS ANGLES COUNTY AN S7 TE OF
SIGNED THIS DAY OF )9_ CALIFORNIA OR HAT 1 AM THE LEGAL OWNER OF AND NT NO TO
OWNER OR RESIDE IN THE E DESCR D RE IDENTIAL PROPER
OWNERS AGENT SIGNATURE
OF PERMITTEE
ALIDATI
CK M 0 CAS
2 9 1- MAY 5 1 Q D 1 4.0 0®2o
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DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
_3W COUNTY OF LOS ANGELES
WILLIAM J FOX, COUNTY ENGINEER BUILDING /
ADDRESS �( /j�
FOR APPLICANT TO F L IN LOCALITY A
BUILDING �+ NEAREST n V �'
ADDRESS J f / �� �� CROSS ST / Y A/ _v _0
LOCALITY DISTRICT NO SERIAL NO PERMIT NO C
NEAREST � A /J R fy S
CROSS ST Q
RECEIVED BY/J Ready for Inspection DATE ISSUED
OWNER
MAIL
ADDRESS S- 2, USE ZONE BK P� OCCUPANCY MAP PG f � PG
CITY TEL NO / -
v
f ;L-2-
cto �
CONTRACTOR 4 CO IMP NO
ADDRESS J /3 JOB NO
CITY TEL NO (S �/ 3� TRUNK PERMIT NO
STATE
REGISTRATION NO COUNTY ROAD PERMIT NO
LEGALSTATE ENCROACHMENT
DESCRIPTION LOT NO PERMIT NO
BLOCK TRAC;5AINDUSTRIAL-4 T WASTE APPROVAL
SIZE OF LOT i� NO OF BLDGS
f J NOW ON LOT CHARGESUSE OF
i�
BUILDINGS CONNECTION CHARGE FEE 1nis (D l L7 U
NO DESCRIPTION OF W15RK WEE REIMBURSEMENT FEE --HOUSE - -
_ PU_BLICSEWE RCONNECTINGTO $ 350 (5 � RECEIPT LNO_ DATE_ BY
HOUSE SEWER CONNECTING TO N
PRIVATE DISPOSAL SYSTEM 100
W RKETO HOUSEISEWERONAILDG OR 1 00 / /> EXCEPTIONRECORDED
ALTER OR REPAIR EXISTING NO DATEBY
SEWER OR DISPOSAL SYSTEM 100
DISCONNECT AND ABANDON SEWER /30 CONNECTION DATA
AND/OR DISPOSAL SYSTEM 1 00
SEPTIC TANK SEEPAGE PITUR �! �,���� / /I
PITS AND/OR DRAINFIELD 200 STATION ° 44f�e�e%t1 DEPTH V U
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 MANHOLEREFERENCEEFERENCE LOWER
_TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ I 1 00 _Y S.af�ln CURB ^P L /M L TO P LAvrV '
AUTHORIZATION TOTAL FEE 1 ,�G yon /S�J 'Ah a.�'Mf�✓,` 41,V"
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR SSIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS J DAY OF IgSl� NEW HOUSE SEWER
OWNEROR I CONNECT ADDITIONAL
OWNERS AGENT _ _ BUILDING OR WORK
ADDRESS S//d2 )7-�Fxt �f-��.. AND/OR DRAINFIELD IT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL[3 DRYWELL I]
CATIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN
ER OF THE ABOVE D SAF CRa1� 1 RES ENTIAL PROPERTY BACKFILL SEPTIC TANKS
SIGNATURE
�l wjl GV- SEEP PIT(S) CESSPOOLS
OF PERMITTEE _
76A642D 663 1/53 �A�