HomeMy Public PortalAbout5227 KAUFFMAN AVE_Sewer__ L
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7* 642D 2/70 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING t—zZ� I
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS ✓ V/Q
COLEMAN W. JENKINS. SUPT. OF BUILDING '
LOCALITY
NEAREST
F R APPLICANT TO FILL IN CROSS ST.
(PRINT OR TYPE ONLY)
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
[BLOCK TRA ADDRESS
F LDGS
IZE OF LOT NOW O LOT CITY TEL. NO.
SE OFUILDINGS DISTRICT NO GROUP CLASS MAP CESSED
PG
CONTRACTOR
ADDRESS t �(/•0 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 @ $5 00
SEPTIC LANK.SEEPAGE PIT OR P.0 NO.
PITS AND/OR DRAINFIELD ® s10 00 CO IMP. NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO. O}.
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER I EASENEMT RECORD INSTR N7 DATE O
WORK TO HOUSE SEWER @ S300 u
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL.DRYWELL.MANHOLE @ $5 00 O
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST WIDENING Ax
SEWER Ow6isposAL SYSTE $300 STATE ENCROACHMENT V
PERMIT NO. W
INDUSTRIAL a�
WASTE APPROVAL Z
OWNER'S PERMIT s 00 CHARGES
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
ADDRESS BUILDING OR WORK
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 ❑ ORYWELL
1 HEREBY CERTIFY THAT 1 A PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY L ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM T E LEGAL NER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE D ED IAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE '" SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
CASH SUPERVISING MECHANICAL ENGINEER
CK O
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