HomeMy Public PortalAbout5233 KAUFFMAN AVE_Sewer__ • 3-64
76A642D - - APPLICATION FOR ERMIT
6A6411
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1'LIII
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING r
JOHN A. LAMBIE, County Engineer ADDR E55 /1
WILLIAM A. JENSEN, Sup't of Building .
LOCALITY �
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T
LEGAL .r
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT (� ADDRESS
NO OF BLDGS _
SIZE OF LOT NOW ON LOT CITY TEL NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
.[_ BK PG
CONTRACTOR 5,
ADDRESS �•f� CONNECTION DAT
CITY NO. STATION DEPTH
TEL.
TATE MANHOLE REFERENCE UPPER
REGISTRATION NO ��& COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGT OM
HOUSE SEWER CONNECTING TO Y. URB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 /�/_���
SEPTIC TANK,SEEPAGE PIT OR CO.I P, O �'�+ P•C.NO. }
PITS ANO/OR DRAINFIELD ® 510 00 JOB NO. a
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT O
PRIVATE DISPOSAL SYSTEM E 1.00 ,✓� `^
'CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIV[R EASEMENT RECORD. I R.NO. DATE- 0
WORK TO HOUSE SEWER •3.00 7+a<
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESS P OOL,DRYWELL,MANHOLE @ $5.00 U
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDEN I NO d
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHME N
PERMIT NO.
INDUSTRIAL
WASTE APP OVAL
OWNERS PERMIT $ 2 00 CHARGEE
AUTHORIZA'T'ION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- R EIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUrILD1NG-_OR WORK '*/A
SEPTIC TANK.SEEP.PIT(S)
I HERE GKN 'DGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND ST TE THAT THE A VE IS CORRECT AND AGREE TO COMPLY
WITH LL COUNTY ORDI NOES AND STATE LAWS REGULATING
PLUM ING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
LRESIDE
H REBY CERTIFY THAT PROPE Y ISTERED AND/OR ALTER,REPAIR,SEWER OR
N ED AS REQUIRED BY �.AM
ANGL G Y AND STATE OF SEWAGE DISPOSAL SYSTEM
F NIA OR THAT 1 AM TGA OF, AND INTEND TO DISCONNECT PLUG AND THE ABOVE DES ID IAL PROPERTY' ABANDON HOUSE SEW ER '
ATUR BACKFILL SEPTIC TANKS ❑
PERMI
SEEP,PIT( ❑ CESSPOOLS ❑
VALIDA ROBERT A. WOOD
CK. M O.7..
SUPERVISING MECHANICAL ENGINEER
LAAO 17uo "1AY 13 0 D 5.00 N