HomeMy Public PortalAbout8737 BURGHARDT RD_Sewer__ CEBUR 3-E6
8 3 APPLICATION FOR PERMIT
CEIJ
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS JLC
WILLIAM A. JENSEN, Sup't of Building
LOCALITY f
NEAREST
FOR APPLICANT TO FILL IN CRO55 B'
LEGAL
DESCRIPTION LOT NO. � OWNER
MAIL
BLOCK TRACT / ( AD DRB"
/ J
NO. OF BLOBS. /' �[ /.
S12E OF LOT NOW ON LOT / CITY ,TEL. NO. (,�( (/
USE OFDISTRICT NO, GROUP MAP PR
BUILpINGS EBSEO BY
)
CONTRACTOR -�" 7- 1)
CONTRACTOR
F.
ADDRESS oZ ZU CONNECTION DATA
CITY
L-e,6_ZLkY TEL. NO-eL �3 STATION LIT 4?, DEPTH Y
I ✓
UPPER
B STATE MANMOLEREFERENCE 2
REGISTRATION NO. COUNTY ✓ ®R
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROMV
I HOUSE SEWER CONNECTING TO Y. CU.B M.L.TO P.L.
PUBLIC SEWER a SS.00 ",c
.C.NO.
SEPTIC TANK,SEEPAGE PIT ORT��
LSC � JOB NO. O
PITS AND/OR DRAINFIELO E10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM 53.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT MY ZZM[Mi RECOflp,INSTR.NO. PATE O
WORK TO HO USE SEWER 53.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL,MANHOLE® $5.00 fy
ALTER,REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING y
SEWER OR DISPOSAL SYSTEM ® 53.00 STA TE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s z 00 CHARGES
AUTHORIZATION I TOTAL FEE _7100 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 SEWER. APPROVALS DATE INSPECTORS SIGNATURE
SIGNED THIS DAY O/F� 19_
OWNER OR NEW HOUSE SEWER Y
OW NERB AGENT �'�P/T�P_I! ll// '(+G/' v/l / CONNECT OR WORK ADDITIONAL
BUILDING
2—✓ -/ C of ✓�'
ADDRESS V— 'l/�Ci�
SEPTIC TANK,SEEP.PIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION gryD/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND
OAGREE COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLV MBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBEIO�N.T�PROPERTY. ABANDON HOUSE SEWER
SIGNATURE )) BACKFILL SEPTIC TANKS ❑
OF PERMITTEE _ SEEP.FITISI ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
cK.
M.O. CASH SUPERVISING MECHANICAL ENGINEER
Ly o9 1 6 JAN 26 1 0 A 57,00-