HomeMy Public PortalAbout6030 BURTON AVE_Sewer__ 7DA842n APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL .
Deparmreni of County Engineer -- - - -
County I Los LINTYAngeles BUILDING /r'�
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS [G7 I.�i1�V !'!p)•% � ;
® CASSATT D. GRIFFIN, SUr-T of EIUILDING LOCALITY •-�!Jt-N Q•� .
FOR APPLICANT TO FILL IN C OSSS ST. v i�� t
LEGAL /O/ OWNER f�Q(a jar
DESCRIPTION LOT N0. �7
MAIL
BLOCK TRACT p�_�Q� ADDRESS J� (L
SIZE OF LOT 1ooXI/S— NOWOONBLOTS CITY TEL. N0.
USE OF DISTRICT NO. GROUP MAP
BUILDINGS �� h Y O
l BK PG
CONTRACTOR
ADDRESS �, ". ",� - CONNECTION DATA
•ii) STATION A DEPTH
CITY '` A 1,' /.., • TEL. N0. MANHOLE REFE NCE _ UPPER
E
REGISTRATION NO. f' � ^'1 0 STATE .f LOWER
� `� �.'- J(-n❑ COUNTY
No. DESCRIPTION OF WORK FEEf
HOUSE SEWER CONNECTING TO TYPE OF CONNECT ON LENGTH FRON
PUBLIC SEWER @ $3.S0 Y- +CURB P.L. M.L. P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00 // 000��� OA J
OVERFLOW SEEPAGE PIT, DRAINFIELD CO. If.1 P. N0. JOB NO.
EXTN..CESSPOOL,DRYWELL,MANHOLE @ $2.00 _
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 / PERMIT NO.
ALTER.REPAIR OR ABANDON HOUSE f INDUSTRIAL
SEWER OR DISPOSAL SYSTEM _C $$.00 WASTE APPROVAL '
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ OO
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 NAM
HAVE AT THIS DATE A CONTRACT WITH THE HER ED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
' TRACTOR TO CONNECT. THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC�EW�i NEW HOUSE SEWER ! �.
SIGNED THIS (� ,C� DAY OF 19 CONNECT ADDITIONAL
OWNER OR 4 � i1 BUILDING OR WORK
OWNERS AGELNT Q✓/ -./�
ADOR ESS //Q Q !Y Q�V•E AND/ORSEPTIC TANK,SEEP,DRAINFIELDPIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELLI]
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 I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY,AND STATE OF DISCONNECT
HO PLUGAUSE D
CALIFORNIA OR THAT 1 AM THE LEGAL AWNERIOF THE ABOVE ABAN _
ER
DESCRIBED RESIU IAL PROPERLY. / I' BACKFILLSEPTIC TANKS O
SIGNATURE t, 'L.I Jl(ti1 n SEEP, PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE �� o ��''- � r.' J1.'iJi. �-✓'\�
JOHN A. LAMSIE, COUNTY ENGIN#R VALIDATION ROBERT A. WOOD. CHIEF PLBG. INSPECTOR
CN. M.0. CASH
L 1 8 9 41n -JAN 16. 1 0 A 3.0 0
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6A64 0 APPLICATION FOR PERMIT
CES08 D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER _
BUILDING AND SAFETY DIVISION BUILDING
JOHN A' LAMBIE, County Engineer ADDREss
WILLIAM A. JENSEN, Sup't of Building ` 1
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN RQBB BT.
LEGAL VP
DESMIMjION LOTNG. /U(� /� OWNER
C MA
B ACK TRP T 5 O AD"RE55
NO, OF BLpGS.
SIZE OF LOT NOW ON LOT CITY TEL NO /
UsE OF
BUILDINGS DISTRICT NO. GROUPMAP PROCESSED BY
_ BK /PG
CONTRACTO J f�
ADDRES CONNECTION DATA
CITY STATION DEPTH
EL. NO.
r
TATE
SUPPER
REGISTRATION NO. IU ��COUNTY MANHOLE REFERENCE LOWER
NO. 1 DESCRIP71ON OF WORK FEE TYPE OF CONNECTIONLENGTH FROM
HOUSE SEWER CONNECTING TO Y, CURB P.L. M-L.TO P,L.
PUBLIC SEWER @ $5.00 P.C.NO EDO
SEPTIC TANK.SEEPAGE PIT OR JOB NO.
PITS AND/OR GRAINFIELD @ 510.00 CO.IMP. NO. U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. w
PRIVATF,OISPDSAL SYSTEM @ $3.00 /N
WORK CONN CT ADDITIONAL
DSE SEWS BLDG.OR @ S3.0O AFFIDAVIT WAIV SEM[ RECORD.INSTR. NO, DATE VF
U
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRVWELL,MANH O LEO
REPAIR OR ABANDON HOUSE �' HWY.OR ST.WIDENING
SEWER dR DISPOSAL SYSTEM @ $3,00 _14J STATE ENCROACHMENT z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT 5 21 00
AUTHORIZATION TOTAL FEE ONNECTION CHARGE FEE CHARGES
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER /
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AN 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 THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OF
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 pISCONNECT PLUG AND
RE5IDE IN, THE AB DESCRIBED flE51 D��EyN//JJJT///IjjjA��-L PRO ERTY. ABANDON HOUSE SEWER
SIGNATURE q /��
OF PERMITTEE _ ///li fn!%i/ i/' /L� BACKFILL SEPTIC TANKS ❑
SEEP.PIT Is) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK.
M.0. CASH
into 8 1 1 8 2 APR 19 1 r A 5.00- QI
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