HomeMy Public PortalAbout5826 BURTON AVE_Sewer__ J8A042D
e @ 0420E.662 11.96 APPLICATION FOR PERMIT-
DIVISION OF BUILDING AND SAFETY SEWER-SEWE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING '
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, Sul'T OF DUILDING LOCALIT
RE
FOR APPLIC�AN//T TOS FILL IN• CROSS ST.
LEGAL
DESCRIPTION LOT N0.`i -rte i Qf( g OWNER
BLOCK TRACT AMAIL
DDRESS /
NO. OF BL G5. CITY TEL. NO.
SIZE OF LOT� b NOW ON LOT
USE OF
BUILDINGS DISTRICT NO.� GROUP BK MAP
CONTRACTOR
,S 3
A CONNECTION DATA
AODRES �y/� ./y. //
CI TEL. NO. / / 3J / DEPTH b '
STATION
MANHOLE REFERENCE
TATE t LOWER
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO yTYPE OF CTION LENGTH FROM
PUBLIC SEWER @ S 3.50 / CURB �C!- M.L. TO P.L. /
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELO @ $3.00 ep�eii
OVERFLOW SEEPAGE PIT.DRAINFIELO CO. IMP. NO. O� I Q POB NO.
O.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $ 1.00 TRUNK PERMIT NO. ROAD PERMIT NO'3 \T Q'
�YJ J/_
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ S 1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PEPMT s t Oo
AUTHORIZATION ITOTAL FEE REIMBURSEMENT FEE
I HAVE.AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS • DATE INSPECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCR� EXISTING DWELLING
TO THE PUBLIC SE R. NEW HOUSE SEWER
SIGNED THIS DAY
CONNECT ADDITIONAL U�
OWNER ORI - BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESH AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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 pBAN DON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LE WNER JOF THE ABOVE
DESCRIBED RESIDENT PROP Y. BACKFILL SEPTIC TANKS ClSIGNATURE SEEP. PIT(S) C] CESSPOOLS ClOF PERMITTEE
1.
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATIO ROBERT A. WOOD.CHIEF PLBG. INSPECTOR
CK. M.0. CASN 1
UQ2577—` FEB 6 4 4.50 tl '