HomeMy Public PortalAbout4847 KAUFFMAN AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER i BUDRESS ABAI 1 ILDING p wI `,N \/
ADF1 1'\e`�.1►�77�A I'1
FOR APPLICANT TO FILL IN LOCALITY =,, C I
BUILDINGNEAREST p�
ADDRESS 7 -�I CROSS ST. S a
LOCALITY DISTRICT N0. SERIAL NO. PERMIT NO.
NEAREST r��a9 /t, � A �C�GAI —s
CROSS ST. �f� �v RECEIVED BY Ready for Inspection DAT 15SUrED
OWNER }�a�aee� 117, 7 3
MAIL' . USE ZONE OCCUPANCY / MAP
ADDRESS j* -,r3?- BK PG
CITY TEL. 0. A— i
CONTRACTOR ` ( Co.IMP.N0.
ADDRESS JOB NO. 1 - i!,l 3
CITY TEL.NO. V-1? Q, G TRUNK PERMIT NO.+'—
/ 7G ❑ STATE
REGISTRATION NO. / �a e. n;vC.QtS:N-Qy ROAD PERMIT N0.
LEGAL ,� /�D Zu• �'y�✓ STATE ENCROACHMENT
DESCRIPTION LOT NO.
'w .21, pA'd ,!;0, 4. PERMIT NO.
BLOCK TRACT. r,i 1_3 INDUTRIAL
WASTE APPROVAL �r
SIZE OF LOT N0.OF BLDG&
NOW ON LOT CHARGES
USE OF CONNECTION C E FEE
BUILDINGS �/.„ls
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
l PUBLICSEWER @ $ 3.50 RECEIPT NO. I AT BY
HOUSE SEWER CONNECTING TO 1
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- I DATE I BY
_SEWER OR DISPOSAL SYSTEM 1.00
'DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION `rt'Z 3 DEPTH CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 C� ,���r^ I / MAN}{,p�E REFERENCE
�Xo W c7� (OPPL
TYPE OF CONNECTION LENGTH.FROM
OWNERS PERMIT $ I 00 � � --R; ; M.L.TO P.L. S
AUTHORIZATION I TOTAL FEE LA
I HAVE'THIS DATE CONTRACTED WITH THE HEREIN. NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS--------------------DAY OF................:--------------- _____19------- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL `
OWNERS AGENT----------------------------------------------------------------___----- BUILDING O R W O R K
. SEPTIC TANK,SEEP.PIT(S)
ADDRESS_________________________
--------------------------....-_...._-----------.._-----------• AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL[-] DRYWELL❑
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE.DESCRIBED RESIDENTIAL PROPERTY. . BACKFILL SEPTIC TANKS[-]
SIGNATURE
�' 4 SEEP PIT(S)C] CESSPOOLS E],,. ,
OFPERMITTEE - _ - -'--------------- ---------------------------
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