HomeMy Public PortalAbout5014 KAUFFMAN AVE_Sewer__ 76A 642D -CE OB-10-71
APPLICATION
pN PERMIT
COUNTY OF LOS ANGELES SEWER—SONAGE DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUA ADILDING
Ess
- LOCALITY
FOR APPLICANT TO FILL IP! CROSS55T. o
LEGAL
DESCRIPTION LOT NO.
MAIL
BLOCK TRACT ADDRESS
/� rNO. OF BLDG S.
SIZE OF LOT6EJ� 6 NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GRBK PG OUP MAP PR SSED BY
BUILDINGS 6AA
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CONTRACTOR ,d -y-- �.�
ADDRESS f CONNECTION DATA
CITY TEL. NO. STATION DEPTH
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO, CLASS LOWER
NO. .DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P:L. M.L.TO P.L.
PUBLIC SEWER @ $7.00
SEPTIC TANK.SEEPAGE PIT OR P.C.NO.
CO.IMP. JOB NO.
PITS AND/OR DRAINFIELD Cm $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. R RMIT NO. a
PRIVATE DISPOSAL SYSTEM @ S3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER "EASEMENT RECORD. INSTR. DATE V
` WORK TO HOUSE SEWER @ S3.00
OVERFLOW,SEEPAGE PIT,DRAINFIELD O
EXTN.,CESSPOOL.DRYWELL.' @ $5.00 HWY. OR ST.WIDENING
ALTER.REPAIR OR ABANDON HOUSE 0
SEWER OR DISPOSAL SYSTEM C $3.00 STATE ENCROACHMENT W
MANHOLE C� $7.00 PERMIT NO. _ G.
INDUSTRIAL N
WASTE APPROVAL
-
OWNER'S PERMIT $ 00 CHARGES
_ CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE fQ6
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC S ER ,,ryry� APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS AY O 19:zg
OWNER OR NEW HOUSE SEWER
OWNERS AGEN
CONNECT ADDITIONAL.-
ADDRESS
DDITIONAL'ADDRESS BUILDING OR WORK.157-0 1
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE TH 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 ❑ ORYWELL ''❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REOUIRED 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 DE C1.71BED ESID E TIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMfTTE BACKFILL SEPTIC TANKS ❑
❑
SEEP.PIT(S) Cl CESSPOOLS
VALIDATION CK. M.O. CASH
La} ' 1 3 50-73. f iY 29 1 0 D 6.00N