HomeMy Public PortalAbout8720 BURGHARDT RD_Sewer__ C08
E83-E4
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER `'
BUILDING AND SAFETY DIVISION BODR£ G'
ss �'h7 y�PG .��PAT ti°�st6
JOHN A. LAMBIE. County Engineer A
WILLIAM A. IENSEN. Supt of Building /
LOCALiTV
NEAREST L
FOR APPLICANT TO FILL IN RBBB ST.
LEGAL
DESCRIPTIONLOT NO. 13 OWNER
.2—
^/ MAIL / •..� //�
BLOCK TRACT / aADDRE /
SIZE OF LOT '� OXIIS` NOW OONB LOTS / CITY fYIX� 1E NO.
USE OF DISTRICT NO. GROUP MAP P ESSEI BY
BUILDINGS
BK PG
CONTRACTOR S
ADDRESS CONNECTION DATA
CIT TEL. NO. - STATION -16
DEPTH
❑ STATE MANHOLE flEFERENCE7 (/ � UPPER
REGISTRATION NO. ❑ COUNTY SLS / I LOWER
NO. GESCRI PTION OF WORK FEE TYPE OF CONNECTION ENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER SS.00
SEPTIC TANK.SEEPAGE PIT OR / 3o P` NO d
PITS ANO/OR DRAINFIELD @ 510.00 CO.IMP. NO. JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM ® 43.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wgYu •s[R[xT RECORD.I NSTR.NO. DATE Ix
TO HOUSE SEWER @ 53.00 O
H
OVERFLOW SEEPAGE WELL.GRAINFIELD v
ALTN.ER.REPAIR OR ABANDON
HOUSE � 45.00 W
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING y
SEWER OR DISPOSAL SYSTEM 53.00STATE ENCROACHMENT N
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 21 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE pEB BEO EXISTING DWELLING APPROVALS
TO THE PUBLIC SE ER. DATE INSPE TORSIGNATURE
SIGNED THIS OAY 1S,
OWNER ORI ` NEW HOUSE SEWER /(p
OWNERS AGEN J� CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS L/
SEPTICTq (S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRARAINFIINFIE4DLD
AND STATE THAT THE ABOVE ICORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES
S ANO STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED PND/OR q LTER. 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
RES JOE
IN. THE ABOVE DES IBED RESIDE TIAL PROpJ=RTY. ABANDON HOUSE SEWER
SIGNATURE �' / BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
BEEP.PIT(S) ❑ CESSPOOLS
(^VALIDATION ROBERT WOOD
cKK// M.I. CASH SUPERVISING MECHANICAL ENGINEER
ACO 6 3 6 2 tO OCT 13 1 0 A 7,0 Q