HomeMy Public PortalAbout6256 BURTON AVE_Sewer__ 24650 INSERTS.
CE808 6.60
TeAeazD S4 D APPLICATION FOR PERMIT- .
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER '-
BUILDING AND SAFETY DIVISION BUILDING 3- '
ADDRESS
IGNN A. LAMBIE, County Eoginner
WILLIAM A. IENSEN, Svp'I of Building LOCALITY '
- NEAREST '
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL �-iT OWNER
DESCRIPTION LOT N0.
BLOCK TRACTq� 'ADDRESS .MAIL 7
NO.OF BLOCS.
SIZE OF LOT NOW ON LOT CITY
USE OF
BUILDINGS QISTRICT GROUP T BK MA PG BY
CONTRACTOR
ADOREss -lij7� CONNECTION DATA
CITY TE[L.NO. ,STATION DEPTH
STATE REGISTRATION N0. / 70—/ B COUNTY MANHOLE REFERENCE
R
No. DESCRIPTI NdWORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SgEWER @ 33.00 TYPE OF CONNECTIO LENGTH FROM OF
PITS ANO/OR DRAINFIELDT OR @ 33.00 Y. RB .L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN.. CESSPOOL.DRYWELL @ S2.00
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM - @ $1.00 CO. IMP. N0. L5 JOB NO. „
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT NO. p
WORK TO HOUSE SEWER @31.00 U
ALTER,REPAIR IOR ABANDON AL SYSTEM HOUSE @ EI.00 STATE ENCROACHMENT
SEWERPERMIT NO. p
INDUSTRIAL F
WASTE APPROVAL W
CHARGES m
OWNERS PERMIT f 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE q REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEW
SIGNED THIS D 1 1S NEW HOUSE SEWER
OWNEq OR CONNECT ADDITIONAL
OWNERS AGE BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP.PIT(S)
AND/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ P 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 AND SEWERS. I SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THA AM AM THS LEG OW ER OF THE ABOVE
DESCRIBED RESIO ""T'- PROPER . BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PITS) ❑. CESSPOOLS ❑
OF PERMITTE
®r VALIDATION, ROBERT WOOD
GA. M.0. (�usN/J SUPERVISING-MECHANICAL ENGINEER
� -`3 NOV 2 3 1. o A 3 .0 G