HomeMy Public PortalAbout5802 KAUFFMAN AVE_Sewer__ - D
S&E-663
6APPLICATION FOR PERMIT. " 1
s,}E eDIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Depaxtmeat of County Engineer
County Of Los Angeles BUILDING '
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® 'CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT NO.
BLOCK - TRACT" ��'�� MAIL ,
ADDRESS
NO. OF BLDGS. Is '
SIZE OF LOT��,® NOW ON,LO �"/ CITY TEL.'NO.
USE OF
DI A DISTRICT NO.- GROUP MAP
BUILDINGS s BK PG
CONTRACTOR
ADDRESSCONNECTION DATA
'STATION s 3 DEPTH
CITY TEL. NO. � -- MANHOLE REFERENCE i1i _
�� ®NATE 7 LOWE
REGISTRATION N0. ❑ COUNTY -
'NO. DESCRIPTION OF WORK FEE,
HOUSE SEWER CONNECTING TO TYPE_OF CONNECTIO LENGTH FROM 'A -
Y. CURB P.L M.L.TO P.L.
PUBLIC SEWER @ $3.50 - '
SEPTIC TANK,SEEPAGE PIT OR '
PITS AND/OR DRAINFIELD @•$3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD /� ^ P. C. NO. -• ,
EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $ 2 00 CO. IMP. NO, { [1 JOB NO..
• HOUSE SEWER CONNECTING TO -
_ PRIVATE DISPOSAL SYSTEM Q $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR / 00 STATE ENCROACHMENT T
WORK TO HOUSE SEWER Q• $1 00 / PERMIT NO. - - Y ••
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL'SYSTEM Q $1.00 WASTE APPROVAL -
CHARGES
CONNECTION CHARGE FEE
OWNER'SPERMIT 1 00
REIMBURSEMENT FEE -
AUTHORIZATION I TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE,HEREIN NAMED CON, .APPROVALS , DATE' INSP 'iOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. .,�/�� - ,NEW HOUSE SEWER l
SIGNED THIS DAY �/L e .e 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK - - -
OWNERSAGENT ,
SEPTIC TANK,SEEP, PIT(S)
ADDRESS ,AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT I H READ THIS APPLICATION CESSPOOL❑ DRYW ELL❑
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
I HEREBY CERTIFY. THAT. I ,AM PROPERLY REGISTERED' AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWDISCONNECT PLUG AND
'
CALIFORNIA OR THAT. I •AM THE LEGAL OWNER OF THE ABOVE
ER
'.DESCRIBED RESIDENTIAL P ERTY. BACKFILL SEPTIC TANKS'❑ ,
SIGNATURE SEEP. PIS) ❑.CESSPOOLS
T
OF PERMITTEE - "
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATIO ROBERT A. WOOD, CHIEF PLEIG INSPECTOR
• CK. Il CASH .5 .