HomeMy Public PortalAbout4810 KAUFFMAN AVE_Sewer__ 76A 642D —CE808—10-71 p 1�P �C p 1T ION OR PER
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COUNTYOFLLIOrSf—ALNNGEL{EYSII �tl If6 Y—Sl�ElfWCER—SEWAGE DISPOSAL_
DEPARTMENT OF COUNTY ENGINEER -
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY _i•��
_. ..,: -.:...�.- ...,.._.,... ... ,._. - .., NEAREST
FOR APPLICANT TO FILL IN cRoss ST.
LEGAL - -
DESCRIPTION LOT NO. 12 OWNER e 'e
MAIL
BLOCK TRACT / e .
ADDRESS
NO. OF BLD G5'
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF • e - DISTRICT N0. GROUP MAP ROLE SS ED BY
BUILDINGS GL'j"'/zi" b BK A �^yP'p^�
CONTRACTOR .7 �4 �•USI (�V LJ
ADDRESS 8a./� CONNE TION DPiTPI
CITY /.V SATE / TEL. NO. �j 7 STATION �rg DEPTH
LICENSE NO,: ,v �G. / LIC MANHOLE REFERRENCCE
GLASS 10 0 LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
USE SEWER CONNECTING TO //7 G�1 Z Y. CURB M.L.TO P.L.
PUBLIC SEWER @ $7.00 ! [J
SEPTIC TANK.SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. }
PRIVATE DISPOSAL SYSTEM @ $3.00 4.
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER .EASEMENT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
E XT N..CESSPOOL.DRYWELL. @ $5.00 O
ALTER,REPAIR OR ABANDON HOUSE HWY.OR 5T.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT W
MANHOLE Q $7.00 PERMIT NO. a INDUSTRIAL N
WASTE APPROVAL Z
CHARGES
OWNER'S PERMIT s 0
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE 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
ALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
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 1 AM THE LEGAL OWNER OF,AAND INTEND-TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENT PROPERTY. ABANDON HOUSE SEWER -
SIGNATURE �` jj/�/`Z; - BACKFILL SEPTIC TANKS ❑
OF PER MTTTEE J/C�\ � SEEP.PIT S)
❑ CESSPOOLS ❑
VALIDATION CK.- M,.O, CASH
1 5.0.0
I/PI