HomeMy Public PortalAbout5644 BALDWIN AVE_Sewer__ 76A 642D-CE808-10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 7NEARE
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FOR APPLICANT TO FILL IN NEARELEGAL DESCRIPTION LOT NO.
MAIL �L` a •��'ifiw�� ! /`r
BLOCK TRACT ADDRESS
SIZE OF LOT NOW OON LOTS CITY C.�L��/f/ TEL. NO.
USE OF
BUILDINGS FRIOUP BK MAPPG PROCESSED BY
CONTRACTORADDRESS r ,[:' CONNECTION DATA
CITY LL/V ITEL. NO.4/q -_3 DEPTH
STATE /� LIC RENCE UPPER
LICENSE NOo--S / 7 OLA$S LOWER
NO. DESCRIPTION OF WORK FEE NNECTION LENGTH FROMHOUSE SEWER CONNECTING TO URB P.L. M.L.TO P.L.
PUBLIC SEWER @ $7.00
SEPTIC TANK.SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD @ E10.00 CO.IMP.NO. J
NOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. PERMIT NO. pr„
PRIVATE DISPOSAL SYSTEM @ $3.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT walvEa Ea MEN ) O D.INSTR.NO. DATE 0
WORK TO HOUSE SEWER @ S3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD cd
EXTN..0 .DRYWELL. @ $5.00 O
ALT EPAIR R ABANDON HOUSE ! HWY.OR ST.WIDEN IN F
SEW ORD SAL SYSTEM @ $3.00 -� STATE EN CROACHMEN _ V
W
MANHOLE @ $7.00 PERMIT NO. d
INDUSTRIAL H
WASTE APPROVA Z Z
OWNERS PERMIT S 3 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRI ED EXISTING DWELLING
To THE PUBLIC SE E . ® APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY "
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OWNER OR iJA NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS r f BUILDING OR WORK
fa"
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 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 ❑
I HEREBY CERTIFY TH 1 AM PROPERLY REGISTERED AND/OR ALTER, EP EWER OR
LICENSED AS REQUIRE LOS ANGLES COUNTY AND STATE OF SEWAG DAL SYSTEM
CALIFORNIA OR THAT THE LEGAL OWNE OF, AND INTEND TO DISCONNECT PLUG AND _
RESIDE IN, THE AB DESCRIBE TI PROPERTY. ABANDON HOUSE SEWER '
SIGNATURE (A�//// 4--1-( BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP.PIT(S) El
VALIDATION CK. M O CASH
V c,0 SI V 2 4 1 0 6,0 a- c�