HomeMy Public PortalAbout8719 BURGHARDT RD_Sewer__ t
CEBOB 3-E4
76A6520 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDINtt FETY DIVISION BUILDING 9,/9
JOAN ounty Engineer ADO REss
WILLIAMSupt of Building
LOCALITY
NEAREST
FOR ATO FILL IN ROSS ST.
EGAL
DESCRIPTION LOOWNE
MAIL
BLOCK TR� ADOR /JS. !/SIZE OF LOT �D/� OWO. OON LOTS I CITY EL NO. Ar_1:ZUSE OF DISTRICT NO. MAP BUILDINGSf
BK PG
[ADDRE�
O
CONNECTSTATION ). DEPTH
/
` ❑ STATE _ UPPER
MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 55.00 /j P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR CO. IMP. NO. I ./30 JOB NO. O
PITS ANO/OR ORAINFIELD @ 510.00
HOUSE SEWER CONNECTING T O TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM ® S3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD. INSTR. NO. DATE a'
WORK TO HOUSE SEWER @ $3.00 O
OVERFLOW SEEPAGE PIT.GRAINFIELD U
EXTN..CESSPOOL.DRYWELL.MAN HO LE@ $5.00 W
ALTER.REPAIR OR ABANDON HOUSE HWM.OR ST.WIDENING y
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACHMENT y
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT E z 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
REIMBURSEMENT FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DES IBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSP O SIGNATURE
SIGNED THIS DAY OF 19 -
OWNER OR ` NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
y BUILDING OR WORK
ADDRESS I
SEPTIC TANK.SEEP,PITIS)
HEREBY ACK OWLEDGE THAT I HAVE READ THIS APPLICATION Ary./OR ORAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINAN C E5 AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER, REPAIR,SEWER OR
LICENSED AS REOUIRED 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 DES RIBED RESI//D//E��EEI}}I//,T�IAL PROPERTY. ABANDON HOUSE SEWER
SIOFATUR PERME EE P SS BACKFILL SEPTIC TANKS ❑
SEEP.PIT IS) ❑ CESSPOOLS ❑
gCK. ALIDATION ROBERT A. WOOD MO. CASH
SUPERVISING MECHANICAL ENGINEER
.
LACO6364-� OCT 1310 A 7.00