HomeMy Public PortalAbout5755 KAUFFMAN AVE_Sewer__ 76A642 0
APPLICATION FC�R PERMIT
B&E•663 9.55 �
DIVISION OF BUILDING ARID SAFETY }' SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDINd -09
WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY 3�
FOR APPLICANT O fILL IN NEAREST
CROSS ST. 1
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT =v MAIL -
ADDRESS
N0. OF BLDGS. `
SIZE OF LOT .� NOW ON LOT CITY ,,,}' TEL. NO.
USE OF
BUILDINGS �, DISTRICTI GROUPK
MAP
BPG
CONTRACTOR /
ADDRESS j j, C CONNECTION DATA
CITY (,._, TEL. NO./- el 40 � STATION ��'j ? 'R I DEPTH v
ATE MANHOLE REFERENCE O / UPPER
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
TYPE OF NECTION LENGTH FROM
HOUSE SEWER CONNECTING TO j Y. URB 1.L. M.L TO P L
PUBLIC SEWERcoli $ 3.50 4
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR /1304
� �. / . C. P70.
WORK TO HOUSE SEWER 1.00 CO. IMP. NO. 4 PJOB NO.
ALTER OR REPAIR EXISTING
EWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT'NO bo y
S _
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
.4ND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD .00 INDUSTRIAL
CESSPOOL- DRYW ELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGESCONNECTION CHARGE FEE
'OWNER'S PERMIT $ 1 p0�0,
AUTHORIZATION TOTAL FEEC REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DES C IBED EXISTING DWELLING APPROVALS JDATE. INSPEC ORAS SIGNATURE
TO THE PUBLIC SEWER _
NEW HOUSE SEWER
SIGNED THISOF w 19t
OWNER OR E / CONNECT ADDITIONAL r
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE R D THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT IAM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS[;
SEEP. PIT(S) ❑ CESSPOOL - o
SIGNATURE
OF PERMITTEE
WILLIAM J.FOX.COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
A'I
6 0 C L': Jul 55 !. 4.5 � (r