HomeMy Public PortalAbout6012 BURTON AVE_Sewer__ 7E 2/]°
6A 692D APPLICATION FOR PERMIT
C
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL Ifl
DEPARTMENT OF COUNTY ENGINEE4.WNER
BUILDING AND SAFETY DIVISIONDING
JOHN A. LAMBIE. COUNTY ENGINEERESS C D /2 `i( Y/
COLEMAN W. JENKINS, SUPT. OF BUILDL)TYEST
APPL CANTTOFILL INs sr:(PRINT OR E ONLY)EGAL
DESCRIPTIONLOT y
MAIL
BLOCK TRACT G 3 ADDRESS'L,S
NO. OF BLDGS. [` ']
SIZE OF LOT {- D NOw ON LOT CITY JQ{7 Ga TEL. N0
USE OF
BUILDINGS DISTRICT NO. GROUP CLA55 MAP ROCESSED BY
BK P5
CONTRACTOR �L 1
ADDRESS /0,0. O y 1•f— CONNECTION DATA
CITY i TEL. NO.,57
2s STATION DEPTH
STATE ,A� /� L y MANHOLE REFERENCE / 'T G° �Q 17 t IS) UPPER
STALICENSE NO,L D CLASS W V
L
NO. DESCRIPTION OF WORK FEE TYPE OFC NNEC.TION LENGTH FROM
HOUSE SEWER CONNECTING TO � �'.• Y. CURB P,L. M.L.TORL.
PUBLIC SEWER I@ SS.00 V
SEPTIC TANK.SEEPAGE PIT OR OR
NO.
FIT.ANO/OR DRAINFIELD @ SHOO. CO.IMP. NO, a JOB NO.
HOUSE SEWER C ONNECTING TO TRUNK PERMIT NO, ROAD PERMIT NO. -7
PRIVATE DISPOSAL SYSTEM @ 53.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT •n es[xlxi RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER ® 33.00 u
OVERFLOW SEEPAGE PIT,DRAINFIELD
ALTER. ESSPOOOR ABANDO.M ANHOLE E5.00 HWY.OR ST,WIDENING O
ALTER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACHMENT U
PERMIT NO, 1(J
INDUSTRIAL
WASTE APPROVAL z
2
OWNERS PERMIT $ ,e 00CHARGES
L
AUTHORIZATION TOTAL FELC /0100 CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'SSIGNATVRE
SIGNED THIS DAY OF 19_ (
OWNER OR NEW HOUSE SEWER -74+,N _
OWNERS AGENT
CONNECT ADDITIONAL
AOp RE55 BUILDING ORRWORK WOgK
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
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE OUSPO5AL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG ANO
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON ROES ESE WER
i
SIGNATURE BACKFILL O �'��� /
OF CLL SEPTIC TANKS
PERMRTEE ❑
_ SEEP.PIT ElSS
IS) CEPOOLS
VALIDATION l JACK R. ALLEN
ER. M.O. ( A..') SUPERVISING MECHANICAL ENGINEER
6 3 7i-JUL 24 1 U A 10.0 0 A96
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76AcezD -
CEBD9IREV.6/J91 APPLICATION FOR PERMIT
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SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
/ FOR APPLICANT TO FILL 1N` DISTRICT
xo. GnouP Mar PROc ED Br
BUILDING T
sI'1 0 ��� 3K MAP
ADDRESS
CONNECTION DATA
LOCALITY `V L.J•`I F[ Le - 1• I
NEAREST STATION DEPTH '
GROSS ST.
y(� t -
UPPER
-
OWNER "` M Q, • 00c) MANHOLEREFERENCE LOWER
n�T TYPE OF CONNECTION LENGTH FROM
MAIL 11 U0�� Y. CURB P.L. ML
TO P.L.
ADDRESS f)
P.C.NO.
CO.IMP.NO. JOB NO.
CITY TEL.NO.
LEGALTRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. o�
BLOCK TRACT
S°►I]� AFFIDAVIT WAIVED EASEMENT RECORD.INSTR.NO. DATE
NO.OF SLOGS.
SIZE OF LOT NOWONLOT HWY.OR ST.WIDENING U/'/
USE OF V
BUILDINGS STATE ENCROACHMENT / p
PERMITNO.
(O 3
1i{� W > 2M SON INDUSTRIAL
WASTE APPROVAL
CONTRACTOR s� 1 y
ADDRESS 'y ��� CHARGES
CITY
CITY SP�u QI F• TEL.NO. 4 CONNECTION CHARGE FEE
STATE -
REIMBURSEMENT FEE
LICENSE NO.�J[ 3'Q s- I CLASS O
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE qj
HOUSE SEWER CONNECTING TO cc
PUBLIC SEWER
NEW ROUSE SEWER O
SEPTIC TANK,SEEPAGE PIT OR I
PITS ANO/OR GRAINFIELD CONNECT ADDITIONAL I[uL
HOUSE SEWER CONNECTING TO BUILDING OR WORK _
PRIVATE
CONNECT ADDITIONAL
SEPTIC TANK,SEEP.PITISI
CONNECT ADDITIONAL BLDG.OR - AND/OR GRAINFIELD
WORK TO HOUSES SEEPAGE PIT
OVERFLOW POOL,DRYWELRA INFIELD CESSPOOL Cl DRYWELL❑ �j..J� 1 i '
EXTN..CESSPOOL,ORYWELL.MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER.REPAIR.SEWER OR I Iry�l
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND � r
ABANDON HOUSE SEWER
BACKLLSEPTIC TANKS El
OWNER'S Permit s
SEFI
EP,PITISI Q CESSPOOLS❑
�
Ly�
AUTHORIZATION TOTAL FEE � -VA-LIwDATI�O�jd1 '
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TOTME PUBLIC BFW R. r / 7
� C�
SIGNED THIS' ptOF 19 J_ 000 , - - .R4-772A
OWNERS AGENT -1 G # 0 O 0 O 1.0
ADDRESS v T.1\G
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION L O O 1.4,0 0 I
AND STATE THAT THE ABOVE IS CORR ECT-AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING O O O ' O 0 U
PLUMBING AND SEWERS. -
' HEREBY C TIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS R LINED BY LOS ANGELES COUNTY AND STATE OF - 0 0'6—79
CALIFORNIA ORT ATIAM THE LEGAL OWNTENDTORE-
S�.NAIU�E
EABO DESCRIBE SIDE OPE
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