HomeMy Public PortalAbout5928 BURTON AVE_Sewer__ B2
76A 6 D/ APPLICATION FOR PERMIT
TEA
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION GUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS. SUPT. OF BUILDING
WA/ qoVj
OCALITY
FOR APPLICANT TO FILL IN NE.REsr
CRDEG $T.
(PRINT OR TYPE ONLY)
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADOflE55 b
NO. OF BLDGS.
SIZELOT NOW ON LOT CTEL. NO. 6 Z
VSE OFr IT1 BVILDING$ DISTRICT NO. GROUP CLASS MAP PROCESSED BY
/ BK �PS
CONTRACTOR L/
ADDRESS CONNECTION DATA
CITY TEL. NO. STATION DEPTH
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO, CLASS LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONN TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO
PUBLIC SEWER @ $5.00
SEPTIC LANK.SEEPAGE PIT OR
PITS ANO/OR DRAINFIELO @ 510.00 CO.IMP, NO. NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD IT
PRIVATE DISPOSAL SYSTEM 0 113.00 1
CONNECT ADDITIONAL BLDG.OR4FFIDAVIT wAlru [ RECORD.INSTR.NO. GATE O
WORK TO HOUSE SEWER ® $3.00 V
OVERFLOW SEEPAGE PIT.GRAINFIELD Of
EXTN..CESSPOOL.DRYWELL.MANHOLE 0 $5.00
YMMIrFABANDON HOUSE HWY.OR ST.WIDENING 0
F
SEWER SYSTEM Q 113.00 STATE ENCROACHMENT U
PERMIT NO. W
a
INDUSTRIAL V)
WASTE APPROVAL Z
CHARGES
OWNERS PEAMIT s - 00
AUTHORIZATION TOTAL FEE1 CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSlE$_T..z625IGNATURE
SIGNED THIS DAY OF I9_
OWNER OR NEW HOUSE SEWER —f y—
OWNERS AGENT
CONNECT ADDITIONAL
aOGRE55 BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP.IIT(S)
AN DSTATE THAT THE ABOVE ICORRECT q AGREE COMPLY ANO/OR GRAINFIELD
WITH ALL COUNTY ORDINANCES
S ANO STATE
LAWS REGULATING ❑
PLUMBING AND SEWERS. CESSPOOL ❑ OflYW ELL
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE A V DESCRIBED RESIDE L P PERT DISCABANONNECT
VSE G WED
SIGNATURE I �A/
OF PERM{FTEE BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS ❑
V LII?ATION JACK R. ALLEN
cn M.D./ CASH SUPERVISING MECHANICAL ENGINEER
iACo 6 8 2M -ul 15 1 0 A 6.0 0- Q
D
S&U-683 3.88 APPLICATION FOR PERMIT
5&6.8tl
DIVISION OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL �4
Department of County Engineer
County of Los Angeles BUILDING Q,
WM.J. FOX, COUNTY ENGINEER ADDRESS _T-7
CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CNEARES
"'S ST r {{��� !�
CROSS 1[LEGL
�{!Z
DESCRIPTION LOT N0.�/• �'l� • 00
OWNER
BLOCK TRACT J S.i�pMAIL �•�. �yt nA'r
ADDRESS g Q �-• r7
SOY LCT iJ NO
. OF BLDGS. p
512E OF LOT NOW ON LOT 'L CITY .O SA•a TEL. NO.
USED tn�� j_ _ _' ��y� DISTRICT 0. 'GROUP MAP
BUILDINGS ��II l:C1N1/+
� PG
CONTRACTOR ¢ V_A.� a � � -
ADDRESS Q��� CONNECTION DATA
CITY �� TEL. N �� r' �Ty'.�y STATION 3 DEPTH
Iq.STATE MANHOLE REFERENC
REGISTRATION k0. / 1.6 3 r ❑ COUNTY LOWER
No. DESCRIPTION OF WORK FEE ��rT
-PUBLIC-SEWER Q $ 3.50 j (f O URB ECTION It.LEL GTO PR M rT ,
HOUSE SEWER CONNECTING TO TYPE
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG. ORD P. C. N0.
WORK TO HOUSE SEWER 1.00 d 0 CO. IMP JON
B O.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.16 AO.Tl
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
OWNER'S PERMIT CONNECTION CHARGE FEE
s o0
AUTHORIZATION TOTAL FEE J— REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECTDATE O THEA ABOVE DESCRBEDCTED WITH THE H EXISTING A IDWELL114G 4ED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS-3-0—DAY OF y 19aL.� NEW HOUSE SEWEROWNER OR
OWNERS AGENT�C(� �- 7 - CONNECT ADDITIONAL
RWORK
/� CONNECT WORK
ADDRESS X91 S' �•/�- -fid''-�-- 'r'!��' AND/ORSEPTIC ANK,SEEP.GRAINFIELD
GRAINFIELDPIT(B)
I HEREBY ACKNOWLEDGE THAT I 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
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR _
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL
CESSPOOLS
SIGNATURE
OF PERMITTEE
WILLIAM J. FOX. COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
I In
�4 6 2 7ar JAN 30 4 5.50