HomeMy Public PortalAbout5115 KAUFFMAN AVE_Sewer__ CE808 3-62
APPLICATION FOR PERMIT
76A642D � .,
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FAR
ING 1 �y�
JOHN A. LAMBIE. COUNTY ENGINEER ESS -� 6 v — � •1q
COLEMAN W. JENKINS. SUPT. OF BUILDING
LITY 1
EST
FOR APPLICANT TO FILL IN S ST. ��
LEGAL .. 1 1 Q ^
DESCRIPTION LOT NO. Q OWNER � ��.
MAIL
BLOCK / TRACT ADDRESS
+" SIZE OF LOT(IG'"'��S NOWOONB LOGS
• CITY 1 TEL. NO, g to
USE OF - - DISTRICT NO. GROUP MAP PROCESSED BY
.` BUILDINGS �• � BK� PGr
� CONTRACTOR ,
ADDRESS CONNECTION DATA
CITY TEL. NO. .._ '. 'STATION6�7 O DEPTH ry
STATE LIC MANHOLE REFEREN UPPER -
LICENSENO.. & s GLASS � OWER
_ ri
NO. .DESCRIPTION OF WORKFEE TYPE O C NN CTION - LENGTH FROMW.I'
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. y�/ CL
PUBLIC SEWER C $5.00
P
SEPTIC TANK.SEEPAGE PIT OR .C.NO.
PITS AND/OR DRAINFIELD C $10.00 CO.IMP. NO. JOB NO. J/ O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO: ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM $3.00
AFFIDAVIT WAIVER I EASEMENT RECORD.INSTR.NO. DATE F-
WORK TO HOUSE SEWER C $3.00 �s W
OVERFLOW SEEPAGE PIT.DRAINFIELD p„
EXTN.•CESSPOOL.DRYWELL.MANH O LEC $5.00 HWY. OR STWIDENING
L tyo
ALTER.REPAIR OR ABANDON HOUSE .
SEWER OR DISPOSAL SYSTEM C $3.00 STATE ENCROACHMENT '
PERMIT NO.
�1 INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s 2 00 .
AUTHORIZATION TOTAL FEE 00
CONNECTION CHARGE FEE
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 SEWER. APPROVALS 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(5)
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATIOJN
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATIN ❑
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OALTAR REPAIR.SEWER OR -
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OE DISPOSAL SYSTEM 3J 4f'
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TDISCONNECT PLUG AND
RESIDE IN, THE ROVE DESCRI ED RESIDENTIAL PROPERTY. gBANDON HOUSESEWER
SIGNATURE OF PERMITTEE BACKFILL SEPTIC TANKS
SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
CK. M.O. `
/ CA SUPERVISING MECHANICAL ENGINEER
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0-69
76A642D APPLICATION FOR PERMIT
6A642 '•
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUI�o1NG r
JOHN A. LAMBIE, Count En ADDRESS :3 l CS- (J A/
County Engineer
WILLIAM A. JENSEN, Sup't of Building '
LOCALITY �� �E
_.:... -..._.. .. _ ,_...-. NEAREST
FOR APPLICANT TO FILL IN CROSS 5T. `c c U D G o
LEGAL 7 M
DESCRIPTION LOT NO. OWNER � G �('�
MAIL
BLOCK TRACT ADDRESS (f�
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY C, TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP BK MAP PG PROCESSED BY
/\
CONTRACTOR �v (!/ V
ADDRESS CONNECTION DATA
'
CITY TEL. NO. STATION EPTH
❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENG FROM
HOUSE SEWER CONNECTING TO Y. _ '/ C RB P.L. M.L.TO P.
PUBLIC SEWER @ $5.00 / r
SEPTIC TANK,SEEPAGE PIT OR /_�.f PYC.NO. O
CO.IMP. O. JOB O.
PITS AND/OR DRAINFIELD @ S10.00 NV
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ S3.00 ^
CONNECT ADDITIONAL BLDG,OR AFFIDAVIT IwAIVEE I EASEMENT RECORD.INSTR.NO. �_iDATE \ (-
WORK TO HOUSE SEWER @ S3.00 '�� V
OVERFLOW SEEPAGE PIT,DRAINFIELD lJJ
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ S5.00 y�
ALTER,REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING Jr/ N
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL /
WASTE APPROVAL
'
OWNERS PERMIT S 21 00 / CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE i
'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
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK +-
ADDRESS SEPTIC TANK,SEEP,PITS) V
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 ElDRYW ELL [I
1HEREBY 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 RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH q