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HomeMy Public PortalAbout4840 KAUFFMAN AVE_Sewer__ 76A 6426'- CE808 - 9/73 APPI C T N FOR PERMOT COUNTY OF LOS ANGELES SEWER-S[_ AGE DISPOSAL u DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ADDRESS f LOCALITY NEAREST FOR APPLICANT TO FILL IN GRoes ST. LEGAL i DESCRIPTION LOT NO. OWNER /CJ 4GG /yJ /��'//� MAIL ' BLOCK TRACT 3// - ADDRESS NO. OF BLDGS. _ SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF _ / BUILDINGS / '� /'Q� ��',f Ge::p DISTRICT NO. GMAP ESSED BY SK PG. G:ONTRACTOR z �. '.U !/ ROUP u —-�,v V ADDRESS 49 zl, CONNECTION DATA P CITY f /^�y�STATE / TEL. NO. � c� F STATION� 63 DEPTH L CENSE ANO:, ��I ��+ / GLA55 �_ MANHOLE REFERENCE 0 -,F.r�Q LOWER NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION 1 LENGTH FROM HOUSE SEWER CONNECTING TO $7.00 © Y. CURB P.L.' M.L.TO P.L. PUBLIC SEWER' . ^ C SEPTIC TANK.SEEPAGE PIT OR P. .NONO.. PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. JOB HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ S3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE WORK TO HOUSE SEWER @ $3.00 O. OVERFLOW SEEPAGE PIT.DRAINFIELD O EXT N..CESSPOOL.DRYW ELL, , @ $5.00 V HWY.OR ST.WIDENING ALTER.REPAIR OR ABANDON HOUSE I= SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT 0 MANHOLE $T 00 PERMIT NO. W INDUSTRIAL WASTE APPROVAL N OWNER'S PERMIT Lis 66p CHARGES CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE 1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING y�p� TO THE-PUBLIC SEWER. APPROVALS ALS DATE INSPECTOR'S 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 IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL Cl DRYWELL Cl ID 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 CALIF C.RNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN. THE ABOVE DESCRIBED RESIDE 'A ROPERTY. ABANDON HOUSE SEWER SIOF ATUR P E6 MTTTEE � i �d ��`.� BACKFILL SEPTIC TANKS ❑ SEEP.PIT(S) ❑ CESSPOOLS ❑ VALE ATION �_ M.O. CASH �.s 3"lo:.nn. 28 1 0 0 1 5.0 0 0