HomeMy Public PortalAbout4819 KAUFFMAN AVE_Sewer__ 76A 649D•- CE808 - 9/73. APPLHCAT00 F®rR PERMO ( f
COUNTY OF LOS ANGELES SEWER—S AGE DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ffCROSS
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FOR APPLICANT TO FILL IN �,��, ��
LEGAL
DESCRIPTION LOT NO. 3 OWNER -��
/ MAIL
BLOCK TRACT /! ADDRESS '
NO. OF BLDG$.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
_BUILD,
UILDINGS �' DISTRICT N0. GROUP MAP P CESSED BY
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^ BK PG �
CONTRACTOR /� �) ..L
ADDRESS *9-/ ail
G".41-s Alf a le
,,�•f') CONNECTION DATA
CITY C°�-j ��/t.�I'� TEL. NO. MANHOLE/REFERENCE STATION, 3 .tel DEPTH
STATE LIC
3' R E� // UPPER
�7 �j
LICENSE NOS_ / GLASS Cluvrew—
No. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM +y
OUSE SEWER CONNECTING TO Y. CURB L.
M.L.TO P.L. 4�
PUBLIC SEWER @ $7.00 /
P.C.NO
SEPTIC TANK.SEEPAGE PIT OR .��
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
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEKENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 d
OVERFLOW SEEPAGE PIT.DRAINFIELD U
EXTN..CESSPOOL.DRYWELL. @ $5.00
H WY.OR ST.WIDENING
ALTER.REPAIR OR ABANDON HOUSE �
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT C:)
MANHOLE (� $7.00 PERMIT NO. IU
INDUSTRIAL CL
WASTE APPROVAL _ N
OWNERS PERMIT Xoz
CHARGES
_ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL 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 I NSPECTOR'S SIGNATURE
w
SIGNED THIS DAY OF 19_ i
OWNER OR NEW HOUSE SEWER :FF��!"�•�`m"—
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
i HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PIT(S)
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 1 AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR'
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFGRN IA OR THAT I AM THE LEGAL OWNER F. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESCRIBED RESIDENT PROPERTY. ABANDON HOUSE SEWER
SIGNATURE / BACKFILL SEPTIC TANKS ❑
OF PE-RM? TEE 44 % 7i *p� SEEP..TPIT(S) [:1 CESSPOOLS
�yAM ❑
V ATIO1V CK.�_ M.O. CASH
31 XJUL 28 15.00gc.