HomeMy Public PortalAbout4833 KAUFFMAN AVE_Sewer__ • '
76A 6 420 -,CE808 - 9/73 ApPL� p O0N FOR ERMO
COUNTY OF LOS ANGELES SEWER-SEVAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ,J y
ADDRESS 7
LOCALITY 4,
FOR APPLICANT TO FILL lid
CROSSSST. yY Cj/9
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT J l , ADDRESS
NO. OF BLDG$.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF ' DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
BK PG
)
GONTRACTOR �/ �� T u .Lso Z) i
ADDRESS ; l Q' '�' �l�J CONNECTION DATA
CITY _ � � TEL. NO. �' ��aSTATION DEPTH
STATE LIC MANHOLE REFERENCE FU UPPER
LICENSE NO:: V CLASS 3 1` / 4
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION ,.,r LENGTH FROM
HOUSE SEWER CONNECTING TO �) Y. CURB -4z-L.�-�- M.L.TO P.L. L�
PUBLIC SEWER $7.00 (^/
SEPTIC TANK.SEEPAGE PIT OR P.C.NO. _ /1
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 WAIVER EASEMENT RECORD.INSTR.NO. DATE ',,,
WORK TO HOUSE SEWER ' Q $3.00 d
OVERFLOW SEEPAGE PIT.DRAINFIELD CD
EXTN..CESSPOOL.DRYWELL. $5.00 V
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT C:)MANHOLE $7 OO PERMIT NO. W
INDUSTRIAL 0-
WASTE APPROVAL fn
OWNERS PERMIT $ 6-0,3 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 p�
TO THE PUBLIC SEWER. APPROVALS
ALS DATE INSPECT 'SSIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP.PIT(S)
1 HEREBY ACKNOWLEDGE THAT I 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 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNT AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFC,RNIA OR THAT 1 AM THE LEGAL OWNER O AND INTEND TO - DISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESCRIBED RESIDENTI PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PE..ITEE
VALIDATION
SEPTIC TANKS ❑
yyy� SPIT
(S)PIS) [3CESSPOOLS C]VALIDATION QE_
K. M.0. CASH
5.0 0 &98