HomeMy Public PortalAbout8746 BURGHARDT RD_Sewer__ EEA°R3" '
76A6420 APPLICATION FOR PERMIT �I
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 7 � q y ��
JOHN A. LAMBIE, County Engineer ADDRESS /✓
WILLIAM A. JENSEN, Supt of Building + }
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROBS ST. IVA
LEGAL
DESCRIPTION LOT NO 0 WNER
MAIL ,
BLOCK �T`RAA.T 'Qq M22 o ADDRESS n' /�
SIZE OF LOT '� OP / NOW ON LOTS CITY �///yG. TEL. NO. Ta- f/
USE OF DISTRICT NO. GROUP MAP P CESSEO BT
BUILDINGS
BH PG
CONTRACTO
ADORESJaeo 0c �J CONNECTION DATA
STATION DEPTH
/ CG
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ® COUryTY S LOWER
NO. GESCRI PT ON OF WORK FEE TYPE OF CONNECTION LEN HFROM
HOUEE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER $9.00
SEPTIC TANK, SEEPAGE PIT OR j 3 3o P.D.NO. r
PITS AND/OR ORA INFIELD SI0.00 CO.IMP.NO. JOB NO. D_
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM ® S3.00
CONNECT ADDITIO NAL BLDG.OR AFFIDAVIT I WAIY[II I [ASIBINT RECORD.INSTR,NO. DATE O
WORK TO HOUSE SEWER ® $3.00
OVERFLOW SEEPAGE PIT.GRAINFIELD
E%TN..CESSPOOL,DRYWELL.MANHOLE® 59.00 U
ALTER,REPAIR OR ABANDON HOUSE NWY.O R ST.WIDENING W
SEWER OR DISPOSAL SYSTEM ® 53.00IA
PERMITSTATE ENCROACHMENT Z
PERMIT NO. _
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DES IBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS D Y�QR / ' 1
OVI
WNER OR NEW HOUSE SEWER SaS
OWNERS AGENT J '
CONNECT ADDITIONAL
ADORERS BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(S)
HEREBY LEDGE THAT HAVE READ THIS APPLICATION AND/OR DRAINFIELO
AND STATE THAT
THE ICORRECT AND AGREE COMPLY
WITH ALL COUNTY
ORDINADIVA NCEE S AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
IHEREBY 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 ANO
RESIDE IN, THE ABOVE DIESCFIBED RESIDIIW PROPERTY. 9 ABANDON HOUSE SEWER
SIGNATURE RMITTEE /rte BACKFILL SEPTIC TANKS El
SEEP.PIT(SI ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
-LACO6 3 5 9-� OCT 13 1 O A 7.0 Or