HomeMy Public PortalAbout5106 KAUFFMAN AVE_Sewer__ =t,
5-65
76A645-65
APPLICATION FORPERMIT
76A 64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUDDING O
JOHN A. LAMM[_ County Engineer ADDRESS
COLEMAN W. JENKINS,Sup't. of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
i // MAIL
BLOCK TRACT /v }V� ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. N
rl
USE OF DISTRICT NO. ROUP MAP PROCESSED BY
PG
BUILDINGS
CONTRACTOR
ADDRESS CONNECTION DATA w
STATION DEPTH
CITY TEL. NO.
LICENSE LICENSE MANHOLE REFERENCE UPPER
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 @ $ 5.00 }
SEPTIC TANK, SEEPAGE PIT OR P.C.NO. d
PITS AND/OR DRAINFIELD C $1 0.00 CO.IMP. NO. JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM C $ 3.00 ad
CONNECT ADDITIONAL &9===GffiFAFFIDAVIT wMi ER EASEMENT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER 0 $ 3.00
A REPA R— O ABANDON HOUSE U
SEWER OR DISPOSAL SYSTEM C $ 3.00 (L
HWY.OR ST.WIDENING CLSNy
EXTN.,CESPOOL. MANHOLE C $ 5.00 STATE ENCROACHMENT b
PERCOLATION TES C $ 5.OG PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
O S PERMIT $ 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE 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_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL 9 >-
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 ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR o 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 ABO E ESC RI BED RE ID TIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(5) ❑ CESSPOOLS ❑
VALIDATIO
CK. M.O. CASH.
LAAO 2 3 8 8,08 MAY 31 1 Q 0 5.0 0-