HomeMy Public PortalAbout4825 KAUFFMAN AVE_Sewer__ 76A 642D :o CE808 - 9/73 APPU` A 11 O® OR PER DT I '
COUNTY OF LOS ANGELES SEWER—SEW GE DISPOSAL_ ILJI
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY �,^fyZx rOr/
NEAREST
FOR APPLICANT TO FILL. IN CROSS ST. SGL
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
ADDRESS
NO. OF BLDGS.
SIZE OF LOT W ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP SK MAP P% ROCESSED BY
CONTRACTOR �% � / �A•`�® .7-
ADDRESS a - •/ �,t'Q_ /9�� CONNECTION DATA
STATION b DEPTH
CITY �G�/�Z��i TEL. NO. Z.
STATE Q / LIC CLASS MANHOLE REFERENCE � kf, / UPPER
LICENSE NO,: O 'Z9RCTt
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P j./ M.L.TO P.L.
PUBLIC SEWER 0 $7.00
SEPTIC TANK.SEEPAGE PIT OR 1 P.C.NO ��_/
PITS AND/OR DRAINFIELD 510.00 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 E111EMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWERQ S3.00
O.
OVERFLOW SEEPAGE PIT.DRAINFIELD G
EXT N..CESSPOOL.DRYW ELL, @ 55.00 V
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ 53.00 STATE ENCROACHMENT CD
MANHOLE $7.00 PERMIT NO.
yi
INDUSTRIAL �
WASTE APPROVAL CO
OVMER'S PERMIT s 0 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION I 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
DATE INSPECTOR'S SIG NATURE
SIGNED THIS- DAY OF 19_ /
OWNER OR NEW HOUSE SEWER ��
OWNERS AGENT '
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
IH
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 ❑
I HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR ALTER,REPAIR•SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCRN IA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO - DISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESCRIBED RES 10ZNT'lpPROPERTY. ABANDON HOUSE SEWER
SIGNATURE y BACKFILL SEPTIC TANKS ❑
OF PEIRMTTTEE `GLt'"
VALIDATION
SEEPptP IT I5) Cl CESSPOOLS ❑
V ALIDATION CK. M-0. CASH
7tio..m 28 1 D 15.00 ,6-%