HomeMy Public PortalAbout5135 KAUFFMAN AVE_Sewer__ mEr trMErTT., ENGINEER
SEWER—SEWAGE DISPOSAL
DIVISION OFB AND SAFETY PERMIT APPLICATION
COUNTY O GELES
WILLIAM J. FO NTY ENGINEERI BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING G NEAREST
ADDRESS 51 X�La����IL CROSS ST.
LOCALITY, -amp a clic* DISTRICT.NO. /SERRIIIAL NO. PERMIT NO.
NEAREST mac'—°�^V�' A/l0 1S �'� Z �J FOS
S
CROSS ST. RQlg �r „ RECEIVED BY Ready for Inspection DATE ISSUED
OWNER �a .�a. Rogsrin
MAIL USE ZONE OCCUPANCY BK MAP PG
ADDRESS //✓l
CITYTEL.NO. Alm 74IJ1i.7 fi
CONTRACTOR Gearpe Xbol
K7,8d�6 or
ADDRESS i7a!? Ei91 E®4kS ��I M1Or JOB NO.
CITY t ® TEL.NO. At p072 TRUNK PERMIT NO.
STATE
REGISTRATION N0. 1, , :I Oar -N,COUNTY, ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION' LOT N0. '5,7 PERMIT NO.
BLOCK TRACTINDUSTRIAL
WASTE APPROVAL
SIZE OF LOTNO OF BLDGS. I
q � 12S IN N LOT CHARGES
USE OF
BUILDINGS Ev]�I_� pr �ilE�`�°?A 1 CONNECTION CHARGE FEE
NO. DESCRIPTION F WORIZ FEE 1
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 3.50 RECEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 _/ d O 1
ALTER OR REPAIR EXISTING I3 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
PITSAND/OR.DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF'CONNECTION LENGTH FROM
Y. CURB P.L. M.L.TO P.L.
OWNERS PERMIT $ 1 00
AUTHORIZATION TOTAL FEE 2-- d p
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS'r.. INSPECTORIS'SIGNATURE DATE
-DWELLING TO THE PUBLIC SEWER
SIGNED THIS - ------ AY OF__ ..... . ...........19 r NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT........ ........ l _ BUILDING OR WORK
ADDRESS..._��� ��`------_ _.__-�_..."___-__ -......____S. SEPTIC TANK,SEEP.PIT(S)'"w
!+ i•••s--- AND/OR DRAINFIELD J
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 i 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 TH EGAL OWN-
ER OF THE ABOVE D CRIBED RESID IA ROPERTY. BACKFILL SEPTIC TANKS�
SEEP.PIT(S)� CESSPOOLS El
SIGNATURE ,Q
OF PERMITTE .. Wil. _ _.� ._.. _�_rE^L1 y
76A642A 663 7/53 I