HomeMy Public PortalAbout8728 BURGHARDT RD_Sewer__ CE50B 3-64
76d6420 APPLICATION FOR PERMIT
IJ
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 9u1LOING p7�$ r
JOHN A. LAMBJE, County Engineer wDORESS
WILLIAM A. JENSEN, Supt o1 Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
DESCRIPTIONLOT NO. ✓ OWNER ��/
MAIL 1
BLOCK TRACT �a— ADORE 5
S
SIZE OF LOT O NOW OON LOT / CITY
USE OF DISTRICT NO. GROUP MAP PR ESSED BY
BUILDINGS
BK PG
CONTRACT
Cv� ri 5� T
ADDRESS CONNECTION DATA
CIT" EL. NO. STATION / qq DEPTH
1y-I. STATE MANHOLE REFERENCE
REGISTRATIO NO. LJ COUNTY �Ji LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENG H FROM ,ev� /
HOUSE SEWER CO NNECTING TO Y.
CURB P.L. M.L.TO P.L. 1
PUBLIC SEWER a $5.00 p-� P,C.NO. Y
SEPTIC TANK,SEEPAGE PIT OR CO.IMP. NO. 3 y JOB NO. O
PITS wND/OR ORA INFIELD 310.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM ® $3.00
CONNECT wOOITIONAL BLDG.OR AFFIDAVIT 1 *11111 us["rov RECORD. INSTR.NO. DATE JIM
WORK TO HOUSE SEWER 53.00 O
OVERFLOW SEEPAGE PIT.GRAINFIELD V
E%TN.,CESSPOOL,DRYWELL.MANHOLE $5.00 3y
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING 11.
y
SEWER OR D15PO5AL SYSTEM ® 33.00 STATE ENCROACHMENT
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
OWCHARGESNER'S PERMIT s z o0
AUTHORIZATION TOTAL FEE / CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA ED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE BE RIBED STING DWELLING
TO THE PUBLIC SEWTO THE PUBLIC SEy/€R APPROVALS DATE INSPE TOR' SIGNATURE
SIGNED THIS J DAY I9
OWNER OR / NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS
/^ / . BUILDING OR WORK
SEPTICI HEREBY ACK OWLEOGE THAT I AVE READ THIS APPLICATION AND/OR
TANK.SEEP.PIT(5)
AND/OR GRAINFIELD
AND STATE THAT THE ABOVE I5 CORRECT AND AGREECOMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE O ISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE OESCRIB D RE3(///IDI�JE-NTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE _ W{�R+ /� B ACKF.Ll SEPTIC TA NKS ❑
OF PERMITTEE ❑
SEEP.PIi 15I ❑ CESSPOOLS
l I
VALIDATION ROBERT WOOD
M.o. cwsH SUPERVISING MECHANICAL ENGINEER
�6 3 6 O� OCT 1 0 A 7.00" a
/'., _