HomeMy Public PortalAbout4836 KAUFFMAN AVE_Sewer__ i
76A 64+D —CE806-10-71 fa PPO ICA N FOR ICBMOT
COUNTY OF LOS ANGELES ASI FOR SEWER—SEVYACBE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ff..DSS
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FOR APPLICANT TO FILL IW �
LEGAL
DESCRIPTION LOT NO. OWNER
y� MAIL
BLOCK TRACT ' O ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAPCESSED BY
BUILDINGS Q
oo BK PG
CONTRACTOR Lr ���8 . `V 1�
ADDRESS efaCONNECTION DATA
CITY '� TEL. NO. 3 d ^� STATION DEPTH
STATEy MANHOLE REFERENCE YJ UPPER
LICENSE NO:; �O G C.L A'SS 6�' kj I ES�R'�
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB � M.L.TO P.L.
PUBLIC SEWER $7.00
SEPTIC TANK,SEEPAGE PIT OR JOB NO.P.C.NO.��fS `�(^
PITS AND/OR DRAINFIELD $10.00 CO. IMP. NO. `` /
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. d
PRIVATE DISPOSAL SYSTEM @ S3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER "EASEMENT RECORD.INSTR.NO. DATE V
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL.DRYWELL. @ 85.00 O
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING N
SEWER OR-DISPOSAL SYSTEM S3.00 STATE ENCROACHMENT W
MANHOLE $7.00 PERMIT NO. d
N
INDUSTRIAL
WASTE APPROVAL Z
OWNERS PERMIT s o
CONNECTION CHARGE FEE CHARGES
AUTHORIZATIONJ 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 SIGNATURE
SIGNED THIS DAY OF 19_ -i/f�
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL 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
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIA PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMTfTEE BACKFILL SEPTIC TANKS 13'i J Y ❑ 'SEEP.PIT(S) E] CESSPOOLS
VALIDATION CK. M.O, CASH
3 l
4,10-n 28 b 1 5.0 0 &98