HomeMy Public PortalAbout5843 1/2 KAUFFMAN AVE_Sewer__ F
CEBOB 5-65
76A 642D APPLICATION FOR PERMI
COUNTY OF LOS ANGELES SEWER—SEWAGE PISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE, County Engineer ADDRESS
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COLEMAN W JENKINS, Sup't of Rulldrng
LOCALITY A
NEAREST
FOR APPLICANT TO FILL IN CRDSS ST
LEGAL
DESCRIPTION LOT NO �. p
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS +�
SIZE OF LOT N W ON LOT ' CITY TEL NO S (f
USE OF DISTRICT NO GROUP MAP PROCESSED Y
BUILDIN
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CONTRA CTOR c__
AD ESS �— COLNNv�EC4TII�_K
r O TATION '-3DEPTH
LICENSE LIC N MANHOLE REFERENCE UPPER
N0. S
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16 OESTRIPTIFON OF WORK FEE TYPE OF CONNECTIO LENGTH VROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TO L
PUBLIC SEWER C• $ 5 00
PC NO,
SEPTTANK, SEEPAGE PIT OR CO IMP NO JOB NO. 0
PITS AND/OR GRAINFIELD C $10 00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, U
PRIVATE DISPOSAL SYSTEM C' $ 3 00 IX
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR NO DATE
WORK TO HOUSE SEWER @ $ 3 00
E R ABANDON OUSE U
SEWER OR DISPOSAL SYSTEM C $ 3 00 W
HWY OR ST WIDENING a
EXTN ,CESS POOL MANHOLE C $ 5 00 STATE ENCROACHMENT Z
PERCOLATION TEST Cl $ 5 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 Oo
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION I TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN N ED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECT 'S SIGNATURE
SIGNED THIS DAY 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECTADDITIONAL
ADDRESS
BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY '0`N DOR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL [:3DRYW ELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERE AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT HE LEGAL O ER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB D CRIBED RES TIA RO RTY ABANDON HOUSE SEWER
SIGNATURE • �� BACKFILL SEPTIC TANKS ❑ �%� 4
OF PERMITTE SEEP,PIT(S) ❑ CESSPOOLS
' VALIDATION
CK M O CASH
' 99 5 1:a ilw 4. 1 0 D 7.00ce