HomeMy Public PortalAbout5728 KAUFFMAN AVE_Sewer__ , R PERM ��
76A64A642D 0-69 APPLICATlO FOR 7;2f
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING.
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building J
LOCALITY IJ9 /e &f
NEAREST
FOR APPLI��C//ANT TO FILL INLEGAL
CROSS ST �JJ
ew
DE RIIPTION LOT NO "v -%
�O' Q OWNE `j G/Q'�'e f17 d
C MAIL
BLOCK TRACT �V 6/ ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USEOF
BUILDINGS e-�J1//7 DISTRICT NO. GROUP MAP PROCESSED BY
CONTRACTOR a �Q/-'`j�f/j/� • ✓ V K PG /L/
ADDRESS %.gyp yGCONNECTION DATA
CITY .�lG��dl TEL. NO /"!� STATION .L d'� DEPTH 61
// /� STATE
REGISTRATION NO. 14GQ"/�7"7' COUNTY MANHOLE REFERENCE / t
NO DESCRIPTION OF WORK FEE TYPE OF CO ION I' LENGTH FROM
,1 HOUSE SEWER CONNECTING TO y� Y URB P L. M L TO P.L
PUBLIC SEWER @ $5 00 P.0 NO. d.
SEPTIC TANK,SEEPAGE PIT OR JOB NO O
PITS AND/OR DRAINFIELD @ S10.00 CO IMP.NO
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N
PRIVATE DISPOSAL SYSTEM @ $300 O
�IYrR E�5[M[
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WNT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $3.00 {
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN,CESSPOOL,DRYWELL,MANHOLE @ S506
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00
AUTHORIZATION TOTAL FEE /fD CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE"PUBLIC SE / DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 1 4_
OWNER ORNEW HOUSE SEWER
OWNERS AGENT ..
CONNECT ADDITIONAL d
BUILDING OR WORK
ADDRES
SEPTIC TANK,SEEP,PITS)
IH
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 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 ❑ _
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO DESCRIBED RES TIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE /�/J� BACKFILL SEPTIC TANKS ❑
OF PERMITTEE / ! SEEP.PIT(5) ❑ CESSPOOLS
ALIDATION ROBER r A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M O CASH
iso0 1 2 5� MAR 1 1 0 D 7LO