HomeMy Public PortalAbout5239 KAUFFMAN AVE_Sewer__ 76A 642D - CE808 - 9/73 APPLICATION FOR PERMIT -
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 6
ADDRESS
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO. OWNER 1 - '
Q a MAIL
BLOCK TRACT O J ADDRESS
qq NO OF BLDGS.
SIZE OF LOT `V NOW ON LOT CITY TEL. NO.
USE OF r DISTRICT NO. GROUP MAP PROCE EO BY
BUILDINGS BK PG
Fj T"
CONTRACTOR 7
ADDRESS j` CONNECTION DAT
Z STATION DEPTH
CITY TEL NO LIC / '
STATE +?i[f C /^J' GLASS Com. '� Cj MANHOLE REFERENCE UPPER
LICENSE NO. ,J T .7 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 0 $7.00
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR
NJOB NO.
PITS ANO/OR DRAINFIELD $1000 CO IMP.NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLUR' AFFIDAVIT 11.1.. .......T RECORD.INSTR. N37 DATE }
WORK TO HOUSE SEWER $3.00 a
OVERFLOW SEEPAGE PIT.DRAINFIELD CC:)
EXTN..CESSPOOL.DRYWELL. $500
ALTER.REPAIR OR ABANDON HOUSE HWY OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT •• CD
MANHOLE $7.00 PERMIT NO. LU
INDUSTRIAL D_
WASTE APPROVAL - C111)
CHARGES -
OWNER'S
PERMIT s
AUTHORIZATION TOTAL FEE
� 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
ADDRESS
BUILDING OR WORK 71
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PIT(S)
AND/OR DRAINFIELD •`
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY. L 'ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFC,RNIA OR THAT 1 A'M T E LEGAL OWNER O AND INTEND TO
i DISCONNECT PLUG AND
RESIDE IN, THE ABOV �D CRIBED RESID / .P_ROPERT ABANDON HOUSE SEWER
SIGNATURE ❑
OF PERMITTEE BACKFILL SEPTIC TA
�/ T�}� SEEP PIT IS) ES POOLS ❑
•ALiL 'PION CK. M.0. CASH
� 2 f/
�'EB 1 it) D �.0 O .A.� .