HomeMy Public PortalAbout6216 BURTON AVE_Sewer__ Parcel Map 501
CEBOBAPPLICATION FOR PERMIT
lBAB120 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL _
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ,i
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS 46
N Burton Ave-
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITY San rabriel
N EAPEST
FOR APPLICANT TO FILL IN `ROSS ST.
EGA`
DESCRIPTION LOT NO. OWNER 4 Irvin McCallum
5 p lMAIL
BLOCK TRACT AA \ 2.-��L ,_� ADDRESS6212 N. Burton Ave,
Ii( .L1.c% ` NO. OF BLDG$,
SIZE OF LOT <Y.9"SNOW ON LOT CITY f1j4hp TEL. NO.
USE OF
✓ DISTRICT NO. GROUP MAP P OCE95ED BY
BUILDINGS B
CONTRACTOR Square Deal Sewer Service �S^ ;,�;�BK PG
ADDRESS 9,33 axson Rd. CONNECTION DATA
CITY ]� TEL. NO. STATION 7 + DEPTH
El n.te
STATE C
MANHOLE RE ERENCE �1 UPPER
LICENSE NO. GLA55 C } I- CIS .rF_''-. ER
NO. .DESCRIP ON OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTI NO TO Y. CURB P.L. M.L.TO P.L.
1 PUBLIC SEWER ® 55.00 00
SEPTIC TANK,SEEPAGE PIT OR CO.IMP. NO. JOB NO, [� � C • O
PIT54ND�OR DRAINFIELD ® 510.00 _ V
HOUSE SEWER CONNECTING TO I TRUNK PERMIT NO. ROAD PERMIT NO. O:
PRIVATE DISPOSAL SYSTEM ® 53.00 O
CONNECT OBLDG.OR AFFIDAVIT elv[• s[II[ RECORD.INSTR.NO. DATE F
WORK TO HOUSE
SE SEW SEW ER
OVERFLOW SEEPAGE PI T.DRAINFI ELD W
E%TN.,CE55POOL,DRYWELL.MANNOLE® 55.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM ® f3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTPIAL
WASTE APPROVAL
OWNERS PERMIT s� z 00 CHARGES
AUTHORIZATION TOTAL FEE I 7 0 CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER, DATE INSPECTOR
'$SIGNATURE
SIGNED THIS DAY OF 19_
OWNEROR NEW HOUSE SEWER 'o_6p 91fk'.
OW NERS AGENT_ CONNECT ADDITIONAL
BUILDING OR WORK /
ADDRESS
SEPTIC TANK.SEEP,PIT I51
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE ICAND AGREE COMPLY
WITH ALL COUNTY ORDINANCES
AND SS ANO TATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL C1DRYW ELL ED
IHEREBY CERTIFY THAT I 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 1 AM THE LEGAL OWNER AND INTEND TO DISCONNECT PLUG ANO
RESI OF
IN. THE ABOVE DESCRIBED RESIDENTI PRO ERTY. ABANDON H OUS EEEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PEflMRTEE SEEP.PIT(5) ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
V°to 6 3 0 2zD SEP 6 1 0 A 7.00-
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