HomeMy Public PortalAbout6144 BURTON AVE_Sewer__ CEB01110-6376A64D APPLICATION FOR PERMIT
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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, Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T.
LEGAL /Gn�i/
DESCRIPTION LOT NO. Q OWNER
�P ry MAIL
BLOCK TRACT L 3 ADDRESS L y
_f NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO. 409 2
USE OF DISTRICT NO. GROUP MpP PROC SED By
BUILDINGS
/ BK PG
CONTRACTOfl I-2—
ADDRESS /3 E /,�s/ , ✓Q CONNECTION DATA
CITY • _ TEL. NO.y..ffff i� /I�yO A'Q STATION L� O C DEPTH
M STATE J J/ PPER
REGISTRATION NO.Z%QQCJ COUNTY MANHOLE REFERENCE
F
DESCRIPTION OF WORK FEE TYPE OF CONNECTION tl LENGTH FRO.
HOUSE SEWER CONNECTING TO Y. CURB M.L.TO PrI(
PUBLIC SEWER Q $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO, a
PITS AND/OR GRAINFIELD ® SIO.00 CO.IMP.NO. JOB NO. O
V
HOUBE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO,
PRIVATE DISPOSAL SYSTEM 43.00 �
CONNECT ADDITIONAL BLDG.OR AFFIDnVIT a [s[ R RD.I R.NO. DA / O
WORK TO HOUSE SEWER ® 33.00 S r
OVERFLOW SEEPAGE PIT,GRAINFIELD uW
EXTN„CESSPOOL,DRYWELL.MANHOLE@ 55.00 y
ABANDON HOUSE HWY,OR ST IOENING N
SEWER Oe n APOSAL SYSTEM ® 53.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT 5 z o0
/^l
AUTHORIZATION TOTAL FEE I, CONNECTION CHARGE FEE V
'I IIAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THEPV BLIC SEW APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF GL 19
OWNER OR NEW HOUSE SEWER /
OWNERS AGENT CONNECT ADDITIONAL /�J ) 1/
�� BUILDING OR WORK // iT
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC DRAIN SEEP,PIT I6) 1 �.-
gN0/OR DRAINFIEIp ,WIAN DTH STATE THAT THE ABOVE IS CORRECT AND AGREE E COMPLY _
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING •�
PLUMBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/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, AN INTEND TO DISCONNECT PLUG AND 7 Y
RESIDE IN, THE ABOV CRIBED RESIDENTIAL PR RTY. pBpNDON MOUSE SEWER
Gi
f• 1
SIGNATURE
OF PERMITTEE / BACKFILL SEPTIC TANKS ❑
SEEP.PIT(51 ❑ CESSPOOLS ❑
1 1
VALIDATION ROBERT A. WOOD
CK M.O. CASH SUPERVISING MECHANICAL ENGINEER
+01 1 8 0; .RLI 0 1 0 A 5.0 Qn q
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