HomeMy Public PortalAbout5709 KAUFFMAN AVE_Sewer__ i
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CE808 ® Y ICATI 1� tl ® E
seoe a.sa COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F��BBDINGESS %'� �L�� 4/JOHN A. LAMBIE, County Ea eerCASSATT D. GRIFFIN, Supt of Suildiag LITYESTFOR APPLICANT TO FILL IN S ST. .
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LEGAL Jt�® / 1f 1
DESCRIPTION LOT N0./JP/4/ OWNER�� � iJ [�
MAIL
BLOCK TRACT ® ADDRESS,
0.OF BLDGS.
SIZE OF LOT NOW ON LOT ,® CITY .� .� -7 7 ;.� ,la L. NO.
USE OF
BUILDINGS . 'yam-, " �J DISTR`IC,�'NO.c GROUP MAP - PR SSSSSEE�D 8
CONTRACTOR 1 �' i•= ` C��'�5 I 'K PG/ I /
ADDRESS�r;jc -r-� �.� 1/ CONNECTION ATA
CITY" 4 EL.NO. STATION I DEPTH
.' STATE MANHOLE REFERENCE
REGISTRATION N6. 7=,i i COUNTY LOWER
NO. DESCRIPTION OF WORK FEE 3
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 -t7 TYPE OF TION 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
EX N..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO �y P.C.N0. -
PRIVATE DISPOSALSYSTEM @ $1.00 CO.IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. /
WORK TO HOUSE SEWER @ $1.00 e
ALTER,REPAIR DSPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
ORS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Z"1 REIMBURSEMENT FEE
TRACTOR TO CIONNE T THE DATE ANT OVE DESCRIBED EXISTWITH THE IVNGAMED DWELLING " APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. �/
SIGNED THIS-D OF 19__ NEW HOUSE SEWER 'ya
OWNER
OWNERS AGENT GENT CONNECT ADDITIONAL -
r L BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I 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 pLTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES__C.OUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I. AM THE LEG& OWN OF THE ABOVE--
DESCRIBED RESIDENT L PROPERTY, �,,✓ 1:7
fi �' BACKFILL SEPTIC TANKS ❑
SIGNATURE / SEEP.PIT(S) ❑ CESSPOOLS ❑
OF PERMITTEE -�' '
4 el
OF LMATION ROBERT A. WOOD
/ CK / M.0. CASH SUPERVISING MECHANICAL ENGINEER