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HomeMy Public PortalAbout5534 BALDWIN AVE_Sewer__ CE603 5-65 - 76A 642D APPLrICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FA..RESS `? JOAN A.LAMBIE, County Engineer JJ� �CQ //yQ,7COLEMAN W. JENKINS,Sup't. of Building T /,l1)FOR APPLICANT TO FILL IN . L+ LEGAL J' DESCRIPTION LOT NO. OWNER �' �(� MAIL BLOCK TRACT ADDRESS NO. OF SLOGS. SIZE OF LOT NOW ON LOT CITY 7—o":1.04,9 1 Q,,LL EL. NO. USE OF c BUILDINGS le DISTRICT NO. GROUP MAP PROCESSED BY CONTRACTOR ��© B f �� (� fi• BK PG � i ele ADDRESS . G•W D CONNECTION DATA CITY TEL. NO. STATION .ice DEPTH � 3 C LIENSE LICENSENO. Q f PP LIC CLASS MANHOLE REFERENCE (/:9 Q LOWER NO. DESCRIPTION OF WORK FEETYPE OF CONNECTIO LENGTH FROM HOUSE SEWER CONNECTING TO Y. CURB P.L M.L.TO P.L. PUBLIC SEWER @ $ 5.00 P.C.NO. I'(�I� a SEPTIC TANK, SEEPAGE PIT OR JOB NO. PITS AND/OR DRAINFIELD @ $1 0.00 CO.IMP. NO. O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U PRIVATE DISPOSAL SYSTEM @ $ 3.00 Ix CONNECT ADDITIONAL BLDG. OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE O WORK TO HOUSE SEWER Cl $ 3.00 'ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM @ $ 3.00 pU W HWY.OR ST.WIDENING G. EXTN.,CESSPOOL, MANHV11OLE @ $ 5.00 STATE ENCROACHMENT Z PERCOLATION TEST @ $ 5.00 PERMIT NO. INDUSTRIAL WASTE APPROVAL OWNERS I PERMIT $ 2 00 CHARGES AUTHORIZATION TOTAL FEE � �� CONNECTION CHARGE FEE 'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXIST DWELLING TO THE PUBLI APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED T S SDAY OF 4"� 19 OWNER OR I NEW HOUSE SEWER OWNERS A ENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS !H. �V I HEREBY ACKNOWLEDGE THAT I HAVE D THIS APPLICATION SEPTIC TANK.SEEP,PIT(S) AND STATE THAT THE ABOVE 15 CORRE AND AGREE TO COMPLY AND/OR DRAINFIELD WITH ALL COUNTY ORDI NCE. AN STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ 1 HEREBY CERTIFY HAT I AM ROPER LY GISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSED AS REQU ED BY LOS ANGLES O TY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR T AT 1 M THE EGA O E OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE BOV DESCRI ED SI N AL PROPERTY. ABANDON HOUSE SEWER q SIGNATURE BACKFILL SEPTIC TANKS Elk-If' OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑ 9 VALIDATION---, / CK. M.O. CASH r. C