HomeMy Public PortalAbout6018 BURTON AVE_Sewer__ CEBOBa3-62A APPLICATION FOR PERMIT
7BA6420 COUNTY OF LOS ANGELES II..II
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION BU 1LO1rvG
JOHN A. LAMBIE. County Engineer ADDREss ���
WILLIAM A. JENSEN. Supt of Buildivg t +
LOCq L1TY
NEPREST
FOR APPLI ANT TO FILL IN RD55 $T. Qr!
LEGAL' IV
j� .^
DESCRIPTION tf; O. I / OWNER of �Y
MAIL
BLOCK }TRACT �9 ADDRESS OQ I+�J/O✓��"
J Qu/9n NOWO°N LOTS CITY TEL, NO ��`{Q
SIZE °F LOT �,/� �.-',[- ,/
BUROF
DINGS � ✓Qn '� DISTRICT NO. GROUP MAP PROCESSED BY
�G 1 BK PG
CONTRACTOR`v •� O + C 1, J _l
ADDREss moi/ ,y (� 0.JLCO/NNECTION DATA �'�C-�
CIT;L , TEL. NO ( Q L/ STATION/`�^ DEPTH �-
\ UPPER
!^� STATE MANHOLE REFERENCE
REGISTRATION NO. / SS GODNTY {/ L 45=1�
No. DESCRIPTION OF WORK FEE TYPE OFC TION LENGTH FROM }
HOUSE SEWER CONNECTING TOY. CURB P.L. M,L.TO P.L.
.D �}
PUBLIC SEWER ® SBO V L+ o
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR U
PITS ANO/OR GRAINFIELD $IO.O° CO.IMP. NO. LJ JOB NO. /s
7
XO V BE SEWER CONNECTING TO [� •�
PRIVATE DISPOSAL SYSTEM ® 43.00 TRUNK PERMIT NO. ROAD PERMIT NO. / �� rO
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wnlv[p s[M[ RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ S3.00 WWWW
OVERFLOW SEEPAGE PIT.DRAINFIELD �•
E%TN..CE55POOL.DRYWELLMANHOLESS.00 Sys'
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING L
SEWER OR DISPOSAL SYSTEM ® $3.00 STATE ENCROACHMENT
PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION TOTAL FEE 7100 CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO, REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUSLIC SE APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THI-S--wAY OF 19y+�e /y
OWN ER OR JaC • ,/` NEW ECT ADDITIONAL
OW NEFS AGENT "I i
r T CONNECT AO°IT IONAL
ADDRESS
O U G NI _ BUILDING OR WORK
sem/
SEPTIC TANK,SEEP.PIT(S)
HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AN IT STATE THAT THE ABOVE Is CORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLV MBING AND SEWERS. CESSPOOL ❑ ORYWELL ❑
I HEREBY CERTIFY THAT I 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 I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG ANO
RESIDE IN. THE AB°V DESI:RIBED RESIDENTI PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
SEEP.PIT(5) ❑ CESSPOOLS 3/76
VALIDATION ROBERT WOOD
11
SPERVI SING MECHANICAL ENGINEER
CK. M.O. CASH