HomeMy Public PortalAbout4815 KAUFFMAN AVE_Sewer__ 76A 642-D - CE808 - 9/73 6=J1f-PU`l A UO If OR PERMUT
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COUNTY OF LOS ANGELES SEWER—SIFWAGE DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
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LOCALITY ��' /
NEARE
FOR APPLICANT
1y O FILL IN CROSSSST.
LEGAL
DESCRIPTION LOT NO. OWNER e-e-) - •e
MAIL
BLOCK TRACT / / ADDRESS
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS .� '��� .a DISTRICT NO. GROUP MAPPS CESSE BY
N
CONTRACTOR ��
/ (I le ,D
ADDRESSslw '4') e'wz- 'e'i we g '4 Cie CONNECTION DATA
CITY ���//� TEL. NO._�j V° STATION 2 EPTH - -
STATE �,., �y,,j g! G ASS MANHOLE REFERENCE J/�1�d
LICENSE NO._ !le G („/ LOWER
NO. I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM �1
11 HOUSE SEWER CONNECTING TO n1 Y. CURB M.L.TO P.L. 6�
(„/ PUBLIC SEWER $7.00 V
SEPTIC TANK.SEEPAGE PIT OR P.C.NO. �J/'�/
PITS AND/OR DRAINFIELD SIO:00 CO.IMP.NO. JOB NO. !6
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ 83.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAIY[Y I SAS[M[MT RECORD.INSTR.NO. t DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD O
E XTN..CESSPOOL.DRYWELL. @ $5.00 V
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ 83.00 STATE ENCROACHMENT c:)
MANHOLE 0 $7.00 PERMIT NO. C7
INDUSTRIAL LV
WASTE APPROVAL 0/3
�
OVVNE:R;S IPERMIT S s o
rCONNECTION CHARGE FEE CHARGES
AUTHORIZATION I TOTAL FEE 14
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING �y
TO THE PUBLIC SEWER. APPRO tlALS DATE INSPECTS SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER � � /'s_ 54-
OWNERS AGENT
- - CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE.TO COMPLY
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING -
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSE DAS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCJ7N IA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO - DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENT L PROPERTY. ABANDON HOUSE SEWER
SIGNATURE � �.� BACKFILL SEPTIC TANKS ❑
OF PE-RMTTTEE�-✓I/df f ❑
ty p yp� SEEP.p�P ITIS) ❑ CESSPOOLS
V ALMATION M.0. CASH
3 .1 9- 2810 ,1) 1 5.0 0 Ast,