HomeMy Public PortalAbout6240, 6242, 6246 BURTON AVE_Sewer__ DEPARTMENT OF COUNTY ENG]INEER SEWER—SEWAGE DISPOSAL 9
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION S
COUNTY OF LOS ANGELES gUILDING
WILLIAM J. FOX. COUNTY ENGINEER I ADDRESS
FOR 'ApPPLICANT TO FILL IN LOCALITY S 04& G1�q�/P105
BUILDIEU NG ^ ,/ N !� y� h/ CNEAREST
ROSS ST.
ADDRSS 0 1 I /C
LOCALITY S�/� C rr_a �1'G(` OISTRI�NO. SERIAL N0. PERMIT N0. L•
CROSS ST.
NEAREST LO /Y G,po 'r/ S
\' �• R�ECE.IVED.`BY Ready for Inspection ®DATE ISSUED
OWNER _ . V 1 L 1 +GhC(] C.l [�YYa�/� �eC ��f•�
MAIL USE ZONE OCCUPANCY BK MAP PG
AO DRESS
CITY TEL.NO. 1� o y
CONTRACTOR .n CO.IMP.NO. /T 7
ADDRESS /err
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CITY TELAO. TRUNK RMIT NO.
STATE
REGISTRATION NO. ® COUNTY ROAD PERMI 10.
LEGAL STATE ENCROA MENT
DESCRIPTION LOT NO. PERMIT NO.
BLOCK TRACT �3 INDUSTRIAL
WASTE APPROVAL
NO.OF
SIZE OF LOT -.1 IfNOW ON LOTS CHARGE
USEOF BUILDINGS D✓� ���//� CONNECTION CHARGE FEE
NO. DESCRIPTION OF—WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO p
PUBLICSEWER 0 $ 3.50 RECEIPT NO. DA IBy
HOUSE S EWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00_
aTCONNECT ADDITIONAL BLDG.OR EXCEPTION RECOR ED
WORK TO HOUSE SEWER 1.00 0
ALTER OR REPAIR EXISTING NO' I DATE IBY
_SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEP ICTANK,SEEPAGE PIT OR / / of
PI TS AND/OR GRAINFIELD 2.DO STATION /174J r(P DEPTH L i�
CESSPOOL—ORYWELL
SP
/_
ECIALCONOITIONSONLY 2.00 / / (• MANHOLE REFERENCE
6 0p(O J UPPER L�11ER
_
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT { a 00 Y. s&e P.l. M.L.TO P.L. aC
AUTHORIZATION TOTAL FEE 6
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INS P ECTO 'SSIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS......._.........DAY OF.........................__.... 19_.__' NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT............................. __„_______.__ gUILDING OR WORK
ADDRESS---------------_------_......_------------------_......_------_------------------ SEPTIC TANK.SEEP.PIT(S)
....__ AND/OR GRAINFIELD
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL 0 DRYWELL C
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS. ALTER, REPAIR.SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
ABANDON HOUSE SEWER
AD STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-;
ER OF THE ABOVE DESCRIBED RE,61DEIAL PROPERTY. BACKFILL SEPTIC TANKS
I _ttt���{{{ / SEEP.PIT(S)[] CESSPOOLS /Z•Za•� y
SICNATU RE
PERMITT
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