HomeMy Public PortalAbout4818 KAUFFMAN AVE_Sewer__ 76A.642D -CE808-10-71 i, PP OC f TOO FOR P tip D'�j'.
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COUNTY OF LOS ANGELES SEWER—SE'di/ IGE DISPOSAL u
DEPARTMENT OF COUNTY ENGINEER - -
BUILDING AND SAFETY DIVI;IN— BUILDING O
ADDRESS G ��/
LOCALITY /• ,
.r:... - ... _....--.. ., ....:e. ...::- NEAREST S
FOR APPLICAN TO FILL CROSS ST.
LEGAL
DESCRIPTION LOT NO. AP
OWNER
MAIL
BLOCK TRACT / ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF P _. .,....: -.
BUILDINGS - '• DISTRICTNO. GROUP MAP ESSED BY
BK PG
CONTRACTOR A; ,C_ E-
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gooREss �� � ��, � �f�•� V "C///OVVV���NN----ECTION DATA
CITY <-4' Cl ";OZ", TEL. NO. •Z�,..5% STATION / DEPTH
STATE LIC 7�� MANHOLE REFERENCE UPPER
LICENSE NO;; •�� GLASS rs� R-
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM �yp
HOUSE SEWER CONNECTING TO Y. CURB P:L.' M.L.TO P.L. _Z15
PUBLIC SEWER 0 $7.00
SEPTIC LANK.SEEPAGE PIT OR P.G.NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO.7r
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. }
PRIVATE DISPOSAL SYSTEM @ $3.00 C
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT 1,WAIVER I-EASEMENT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ S3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD ce
EXTN..CESSPOOL.DRYWELL.- @ $5.00 O
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
F
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT W
MANHOLE - PERMIT NO. Q.
$7.00 N
INDUSTRIAL
WASTE APPROVAL z
OWNER'S PERMIT $ 4f 65-oD CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
'.i TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTW 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 I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. t CESSPOOL ❑ DRYWELL [:1
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE.DISPOSAL S YSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBEDRJ�RE:�XfRTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKSOFPERMITTEE /� eK./ SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION CLK. M..0. CASH
3 2 0t`_'-pa' 28 10 D 1 5.0 0 A9�.
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