HomeMy Public PortalAbout8718 BURGHARDT RD_Sewer__ DE8083-Ea
76A642D APPLICATION FOR PERMIT �I
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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 `ROBS ST.
LEGAL
DESCRIPTION LOTHO. /07 OW NE
MAIL
BLOCK TRACT ADOR SS /f
NOF
SIZE OF LOT
60 41 /r NOW00N LOTS / CITY TEL. NO. OI/
USE OF
BUILDINGS0 DISTRICT NO. GROUP MAPP ESSED BY
BK PG
CONTRALTO � 1
ADDRESS ,� CONNECTION DATA
CI /TEL. NO. _ _ STATION /� DEPTH. %
(O
UPPER
e STATE MANHOLE REFERENCE /2/
REGISTRATION NO. COUNTY ✓ LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LEN TH FROM )
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEW ER ® fS.00
SEPTIC TANK,SEEPAGE PIT OR JOB NO.NO.
/ 1}
PITS AND/OR DRAINFIELD 510.00 CO.IMP.NO. OB
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM ® $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT Alv 4R.NO. DA
rEKrNT RECORD.INSTTE C
WORK TO MOUS E SEWS R $3.00 O
OVERFLOW SEEPAGE PIT,GRAINFIELD ~
EXTN.,CESBPOOL,ORYWELL.MANHOLE $5.00 V
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING W
SEWER OR DISPOSAL SYSTEM $3.00In
STATEENCROACHMENT Z
PERMIT NO. _
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT E 2 00
AUTHORIZATION TOTAL FEE /F/ 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
TO THE PUBLIC B ER. APPROVALS DATE INSP O SIGNATURE
SIGNED THIS DAY O 1,(/L 1965
_ /
OWNER ORHOUSESEWER (F
OWNERSAGENT / ✓N' CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOW DGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP.PIT(6)
ANO/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWCRS. CESSPOOL ❑ oRYW ELL ❑
I HEREBY 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 I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE W �� � /T OACKFILL SE PT IC TANKS ❑
OF PERMITTEE SEEP.PITIS, ❑ CESSPOOLS ❑
/ �V
� ALIDATION ROBERT
SUPERVISING MECHAA WOODNICAL ENGINEER
CN.
M.0. CASH
LA(i0 6 3 6 3 OCT 13 1 0 A 7.0� v