HomeMy Public PortalAbout6120 BURTON AVE_Sewer__ 24650INSERTS'. -
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D APPLICATION FOR PERMIT .
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER -
BUILDING AND SAFETY DMSION a�oaessG Y V S7�.
JL A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt o1 Building LOCALITY
NEAREST •T—
FOR APPLICANT TO FILL IN CROSS ST. / 7�
LEGAL OWNER
W --�c•�L
DESCRIPTION LOT NO. ^�v
BLOCK TRACT MAIL
ADDRESS / / ;} /
NO.OF BURGS.
SIZE OF LOT NOW ON LOT CITY r TEL. NO.
USE OF
BUILDINGS DISTRICT N0. GROG MAP
PG PROCESSED BY
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- CONTRACTJZ
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ADDRESSCONNECTION DATA
CITY TEL.NO Q¢ STATION .� DEPTH
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STATE MANHOLE REFERENCE
REGISTRATION NO. LlCOUNTY r V r
No. DESCRIPTION OF W K F E
HOUSE SEWER CONNECTING TO (�0 -
PUBLIC SEWER @ $3.00 TYPE OF CONNECTIO LENGTH FROM J)
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL. DRYWELL @ $2.00 P C NN0O
HOUSE SEWER CONNECTING TO CO. IMP. NO. JOB .
PRIVATE DISPOSAL SYSTEM @ $I.00
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0. p
V
ALTER. REPAIR OR ABANDON HOUSE STATE ENCROACHMENT f4
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT N0. O
INDUSTRIAL U
WASTE APPROVAL W
CHARGES m
OWNER'S PERMIT $ 2 Do ' CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ( V REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- 5
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER �S7i
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP. PITS)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
` WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING Al. SE S, SEWAGE DISPOSAL SYSTEM
1 HEREBY CER THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS R IRED .BY LOS ANG S COUNTY ANO TATE OF ABANDON HOUSE SEWER A
CALIFORNIA 0 T 1 AM THE LEGA HER F HE ABOVE
DESCRIBED R N IAL PROPERTY. BACKFILL SEPTIC TANKS ❑ ,w ry// A_
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS L%I �/ V I �I(IFYInAG
OF PERMI
®" VALIDATIONS ROBERT A. WOOD
C& X.0. l/�cns/HJ SUPERVISING MECHANICAL ENGINEER
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