HomeMy Public PortalAbout5927 KAUFFMAN AVE_Sewer__ a
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& 869 if-'39 APPLICATION FOR PERMIT
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'DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE -DISPOSAL
Department of County Engineer
COUIIty of Los-Angeles BUILDING V JOHN-A. LAMBIE, COUNTY ENGINEERADDRESS CASSATT D. GRIFFIN, SUPT of BUILDING LOCALITYFOR-APPLICANT TO' FILL IN CROSS sr. !E]LEGALOWNERDESCRIPTION LOT NO. MAILBLOCK TRACT • � ADDRESSNO. OF BLDGS. CITY -
'SIZE OF LOT - NOW ON LOT
USE OF,
BUILDINGS ,� -DISTRICT NO. GROUP MAP -
'BK PG
CONTRACT: z
ADDRESS ��.j � CONNECTION DATA �'—�—
STATION DEPTH
CITY TEL. NO. . MANHOLE REF RENCE 'r - UPPER.
ST4$TE LOWER
REGISTRATION N0. �/ ( ❑ COUNTY - -
NO. DESCRIPTION �K' FEE
HOUSE SEWER CONNECTING TO TYPE OF CONN TION LENGTH FROM
Y. CU B_ 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,MANHOLE @ $2.00 CO. IMP. N0. JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. PERMIT NO. _
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT. -
WORK TO HOUSE SEWER @ $1,00 PERMIT NO. '
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL •'
CHARGES
_ CONNECTION CHARGE FEE-
OWNER'S PERMIT 3 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED Cori- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE-PUBLIC SEWER. - NEW HOUSE SEWER'
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL _
OWNER OR BUILDING OR WORK ' "? �
OWNERS AGENT SEPTIC TANK,SEEP,�PIT(S) '
ADDRESS AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL Ej DRYWELL'❑ r
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 EBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LIC SED AS REQUIRED BY ,11OS ANGELES COUNTY A 'D STATE OF '
CAL fORNfA OR THAT I AM THE- LEG AJl OWNER 0 THE ABOVE ABANDON HOUSE SEWER
DES,CRIB0 RESIDENTIAL PROPER
T
Y. BACKFILL TQ SEPTIC.T ❑.
ElSIGN7lT /R d/G���L•� ('/0,Fa �� SEEP.PIS) CESSPOSSPO OLS
OF ITTE, • _ '•
JOHN A. LA0BIE,'COUNTY ENGINEER VALIDATIQN--,` ROBERT A. WOOD;CHIEF PLBG. INSPECTOR
r, CK. Id.
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