HomeMy Public PortalAbout5725 KAUFFMAN AVE_Sewer__ &r7
CE606 5-65 APPLICAT N FO
76A 642D R PERMITCOUNTY OF LOS ANGELES Y
DEPARTMENT OF COUNTY ENGINEER
SEWER-SEA E DdSPOSAL
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
COLEMAN W. JENKINS,Sup't. of Building e
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T
LEGAL00,
+
DESCRIPTION LOT NO 7� OWNER
j.
MAIL
BLOCK TRACT ADDRESS
_7T
NO OF SLOGS.
SIZE OF LOT OW ON LOT / CITY TEL -NO.
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS II��
CONTRACTOR �U J� / PG
ADDRESS �/��` CONNECTION DATA
CITY
`��._('� STATION DEPTH /
R TEL d `d I
LICE NSE�� ��� LICE NS Vv�T MANHOLE REFERENCE
NO CLASS pL. LOWER
NO GESCRIPTION OF WORK FEE TYPE OF CO TION LENGTH Ff O_
HOUSE SEWER CONNECTING TO Y CURB P L M L.TO P L
PUBLIC SEWER C $ 5 00
C NO
PT IC TANK, SEEPAGE PIT OR CO IMP: NO 3 D JOB NO O
PITS AND/OR DRAINFIELD @ $10 00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NOz-3-3,60k
^J� CJ
PRIVATE DISPOSAL SYSTEM C' $ 3 00 I G
CONNECT ADDITIONAL BLDG OR AiFFIDAVIT WAIVEN EASEMENT RECORD INSTR NO DATE O
WORK TO HOUE SEWER C $ 3 00 • • 0
AB D N HOUSE
SEWER OR DISPOSAL SYSTEM C $ 3 00
UVEHFLOW SEEPAGE HIT, ORAtNFtELU HWY OR ST WIDENING CL
EXTN.,CES SPOOL, MAN14CLE C $ 5 00 STATE ENCROACHMENT V)
PERCOLATION TEST C $ 5 OG PERMIT NO z
INDUSTRIAL ,
WASTE APPROVAL
CHARGES
OWNERS ' PERMIT S z o0
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 EXI IN `DWELL[
TO THE PUBLIC SEWER y APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF +.
OWNER OR EW HOUSE SEWER
OWNERSAGENTZ CONNECT ADDITIONAL
_ BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP,PIT(S)
1 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 I CESSPOOL ❑ DRYWELL ❑
IHEREB ERTIFY THAT 'I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENS AS REQUIRED BY O ANGLES COUNTY AND S ATE 'OF SEWAGE DISPOSAL SYSTEM
CACI RNIA A H LEGAL OWNE AND O DISCONNECT PLUG AND
RE E H ABOVE S ED R DE�PR ABANDON HOUSE SEWER
5 G ACKFILL SEPTIC TANKS ❑
F PE ITTEE ❑
❑ CESSPOOLS
VAL ATIODt�
CK M O CASH
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