HomeMy Public PortalAbout5915-5915 1/2 KAUFFMAN AVE_Sewer__ C1808 3-64
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES I
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Cl
FNEAREST
LDING S An
JOHN A. LAMBIE, County Engineer RESS `v\
- WILLIAM A. JENSEN, Sup't of Building T —
ALITY ` l
SSST.
FOR APPLICANT TO FILL IN
LEGAL
DESCRIPTION LOT NO _OWNER \� Q\ :s7
`+ MAIL
BLOCK TRACT 5 V` ADDRESS -
^�7 NO OF BLDGS 4
SIZE OF LO1q0 e 9 NOW ON OT CITY TEL. NO.
USE OP
BUILDINGS�6v $ Q,� DISTRICT NO. GROUP MAP P OCES BY
-04 _ BK PG �
CONTRACTO V� a
ADDRESS �^ CONNECTION DATA _
CITY—S-
IT r�\��j TEL NO. '36 �J STATION ?�Q /Q DEPTH
REGISTRATION NO. \,� C- 7 ` COUNTY TATE MANHOLE REFERENCE "'�/ UPP
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIO /(P.QL. LEN G H FROM/I—
HOUSE SEWER CONNECTING TO Y._ CURB M.L O P L
PUBLIC SEWER 55 00 l ,
P.C.NO.
MPNO
SEPTIC TANK,SEEPAGE PIT OR (/[� 0-
PITS AND/OR DRAINFIELD @ $1000 0
CO.. . . JOB NO.
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM E3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIv[I1 1111M1NT RECORD INSTR.NO DATE O
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN,CESSPOOL,DRYWELL,M AN HOLE @ $3 00 t U
ABANDON HOUSE H Y O ST W E I a
SEWER OR-B18P09+►L SYSTEM @ $300 �� ST N ACHMENT
PER _
Al
INDUST IA
WAST V
O R'S PERMCHARGES
IT $ z o0
AUTHORIZATION TOTAL FEE 41—coCONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. - APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19— _
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL [IDRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND S OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR Z ATHE EGAL OWNF�R OF, AND TEND TO DISCONNECT PLUG AND
RESIDE IN, THEVE �11L
�RESIDENY4,4L PROPE Y. ABANDON HOUSE SEWER
SIGNATURE ,V\��`� BACKFILL SEPTIC TANKS ❑
OF PERMITTEE �.x SEEP,PIT(S) ❑ CESSPOOLS ❑ '
VA DATION ROBERT A. WOOD
M G" CASH SUPERVISING MECHANICAL ENGINEER
�i,C,a 4 2 4 0- AUG 19 1 Q - 5.00-