HomeMy Public PortalAbout5421 BALDWIN AVE_Sewer__ Iases�(?
76606 6. A
60 APPLICATION FOR PERMIT
76A642D COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER _
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building LOCALITY
NEAREST
FOR APPLIC,'AN TO FILL CROSS ST.LEGAL
�J
DESCRIPTION LOT NO. Z� OWNER Il 7 OA S
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF + /� �� DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS v
CONTRACTOR
i
ADDRESS AIVA)1.57'0&6 CONNECTIONtDATA
CITYjU� 2L't/y Al ® TEL.N0. ] STATION DEPTH
REGISTRATION NO. I��� �' G r �' ElCOUNTY MANHOLE REFERENCE
LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO p�
PUBLIC SEWER @ $3.00 �v / FE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT ORCURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESSPOOL, DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB NO. a
_ WORK CONNECT H ADDITIONALUSE BLDG.OR @ $I OO TRUNK PERMIT NO. ROAD PERMIT NO. G� G 73. V
SEWER OR PAIRO R ABANDON SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT W
PERMIT NO. F
INDUSTRIAL U
WASTE APPROVAL W
CHARGES
OWNER'S PERMIT g 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE &FJ REIMBURSEMENT FEE
NAMED CON-
TRACTOR TO CHAVE AT IONNECT THE ABOVE DESCRIBED ES DATE A CONTRACT WITH THE XISTIJNG DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS D Y OF 19_ NEW HOUSE SEWER
OWNER OR •� CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY 1 CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. ^ SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF T E ABOVE BACKFILL SEPTIC TANKS C3DESCRIBED RESID TIAL PROPERTY. SEEP.PIT(S) ❑ CESSPOOLS [:ISIGNATURE
OF PERMITTE
®r ALIDATION ROBERT A. WOOD
V
CK. M.o. CASH SUPERVISING MECHANICAL ENGINEER
0 7.(D