HomeMy Public PortalAbout6150 BURTON AVE_Sewer__ CE808 p 10-63
76A64 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE. County Engineer ADDRESS `J
WILLIAM A. JENSEN, Supt of Building
LOCALITY � Q
NEAREST
FOR APPLICANT TO FILL IN aDsS sT.
LEGAL
DESCRIPTION LOT NO. !V OWNER L
MAIL �I ✓
BLOCK TRACT ADDRE50
NO. OF BLOCS
SIZE OF LOT NOW ON LOT CITY TEL. NO. �l?/
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESS BV
BK PG [
CONTRACTOR +� _Awkv T _
E /�
ADDRESS Fe CONNECTION PAM
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CITY - TEL. NO. MpNMOLE REFERENCE
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REGISTRATION NO. H COUNTY
STATION 57 PPE
STATE
L�NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION ,LGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ S5.00 a
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O
PITS ANO/OR GRAINFIELD @ SIO.00 CO. IMP. NO. JOB NO. v
HOUSE SEWER CONNECTING TO TRUNK PERMIT N°. ROAD PERMIT NO. IX
PRIVATE DISPOSAL SYSTEM @ 53.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT AIIII [ASND RECORD. INSTR.NO DATE VF
WORK TO H OUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,GRAINFIELD W
EXTN..CESSPOOL,DRYWELL,MANHOLE @ $SAO d
AYDON HOUSE HY0R ING
SE � Z
O gSSTEM S3A0
STATE ENCR°ACHMENTt Y✓SJR
PERM N .
IN° STRI
WASTE AP
OWNERS PERMIT 5 z oo D A
AUTHORIZATION TOTAL FEE � CONNEcHA RG E
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAME. CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SE DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF� t -
OWNER OR NEW HOUSE SEWER
OW NERB AGENT L
CONNECT A
BUILDING ORR WORK WORK
ADDRESS
SEPTICTANK.RAINFI LPIT(5)
HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION pryD/OR GRAINFIELD
ANDWITH
STATE THAT THE ABOVE IE CORRECT AND AGREE E COMPLY
WITH ALL COUNTY OROINA NOES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERE. ANO/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSALSYSTEM
CALIFORNIA OR THAT I Al HE LEGAL OWNER OF, pNp NTEND TO DISCONNECT PWG AND
RESIDE IN, THE ABOVE CRIBE. RESIDENTIAL PRO V.
ABgN DON HOUSE SEWER
BIGNATURE -
OF PEq MITTE SEEP IT(.)LL El TANKS ❑
SEEP.PIT 151 ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
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