HomeMy Public PortalAbout5426 BALDWIN AVE_Sewer__ 24650 INSERTS
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76A642080 APPLICATION FOR PERMIT -`
COUNTY OF LOS ANGELES E SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A LAMBIE County Eng�near
WILLIAM A JENSEN Supt
of Building �� 1
LOCALITY
NEAREST
FOR APPLICANT TO IN CROSS ST
LEGAL f 1
DESCRIPTION LOT NO OWNER
Jr
BLOCK TRACT MAIL
ADDRESS
NO OFBLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF War'
DISTRICT NO GROUP MAP` PROCESS
BUILDINGS ED BY
BK PG x
CONTRACTOR (J
ADDRESS r NNECTION DATA
CITY TEL NO�L_ Q ���(]p O,f� STATIO
STATE
REGISTRATION NO ,J� O LJ COUNTY MANHOLE REFERENCE UPPER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L
PITS AND/OR DRAINFIELD @ S3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO 0.
CONNECT ADDITIONAL BLDG OR ITRUNK PERMIT NO ROAD PERMIT NO V
WORK TO HOUSE SEWER @ $1 00
SEWER OR DISPOSAL SYSTEM ALTER REPAIR OR ABANDON HOUSE @ $1 00 STATE ENCROACHMENT pq
PERMIT NO O
INDUSTRIAL }µj�
WASTE APPROVAL W
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTORSSIGNATURE
TO THE PUBLIC SEWER yy g
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION `
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [I DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT 1 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 THE ABOVE
DESCRIBED RESIDENTL ROPERTY BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS n
OF PERMITTEE V
®� VALIDATION ROBERT A WOOD
CK m 0 CASH SUPERVISING MECHANICAL ENGINEER,
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LCCaC 8 8 911-0 AN- 1 D 5 l3tJ C,