HomeMy Public PortalAbout5142 KAUFFMAN AVE_Sewer__ TEMPLE CITY
CE80820.59 -// PPLOCATN -®N FOR Il ERI1V T `
COUNTY OF LOS ANGELES SEWER-SEWAGE DUSPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, Count. Engineer ADDRESS
CASSATT D. GRIFFIN, Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN ceoss ST.
LEGAL OWNER
DESCRIPTION LOT N0. c C
BLOCK TRACT. �j MAIL '
ADDRESS ,.iNO.OF
-
i;. SIZE OF LOT�p� (JX .NOW ON LOTS / CITYL.�%•/ TEL. NO.
USE OF / n
h BUILDINGS ,�C�'�G�P G/�% DISTRICT .0. GROUP "MAP PROCESSED BY
BK PG
CONTRACTOR
�I
ADDRESS. CONNECTION DATA
CITY TEL.NO. STATION DEPTH '
❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY LOWER
.No. DESCRIPTION OF WORK FEE 0 q
HOUSE SEWER CONNECTING TO L.cC--C I V I ^�
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM-
+ SEPTIC TANK,SEEPAGE PIT OR Y. - CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.. CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.N0. -
_ PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB NO.
'CO�NNE OTHOUSEISEWERBLDG.OR @ $I 00 TRUNK PERMIT NO. ROAD PERMIT NO.
3 j LTER„_REPAIR OR ABANDON HOUSE U�v1 STATE ENCROACHMENT -
r S OR DISPOSAL SYSTEM @ $1.00 V PERMIT NO.
INDUSTRIAL -
WASTE APPROVAL
d
CHARGES
OWNER'S PERMIT Z Dp CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE'AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- -
' TRACTOR TO CONNECT.-THE ABOVE-DESCRIBED EXISTING DWELLING APPROVALS DATE - INSPECTOR'S SIGNATURE
TO THE PUBLIC'SEWER: .
SIGNED THIS DAY OF 1,Z Ll
NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _ '' '1—:6—
BUILDING.OR WORK
ADDRESS "5 ! / s !r` _� SEPTIC TANK,SEEPAND/OR DRAINFIELD.PIT(S) -
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING - ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM- PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE OVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL P PERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP. PIT(S) ❑ CESSPOOLS ❑ -
OF PERMITT 2
®F VALIDATION ROBERT A. WOOD
CK, ai,o. CASH SUPERVISING MECHANICAL ENGINEER
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