HomeMy Public PortalAbout5935 KAUFFMAN AVE_Sewer__ ,°_63
76A642D APPLICATION FOR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING /
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO. 12, -7- OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF SLOGS n J�
SIZE OF LOT NOWACINeLOT CITY ' � TEL NO.
USE OF 04, DISTRICT NO GROUP MAP OC ESSED BY
BUILDINGS
BK PG /y
CONT RACTO Jam'•)/ ( /-� -[/,i(J�[.�,/`/'
ADDRES CONNECTION DATA
w^ //r STA DEPTH
CITY TEL. NO
STATE MAN..LE REFERENCE UPPER
REGISTRATION NO COUNTY LOWER
NO DESCRIPTIO Oft-WORK FEE TYPE OF CONNECTION LENGTH FROM
OUSE SEWER CONNECTING TO Y CURB P,L. M L TO P L
PUBLIC SEWER @ $5 00
P C.NO. O
SEPTIC TANK,SEEPAGE PIT OR CO.I
PITS AND/OR DRAINFIELD @ $10.00 OB NO. V
HOUSE SEWER CONNECTING TO K RM O ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3 00 ce
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I W�ENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ S300
OVERFLOW SEEPAGE PIT,DRAINFIELD Y.I
EXTN,.'ESSPOOL,DRYWELL.MANHOLE @ E5 00
ALTER.REPAIR OR ABANDON HOUSE HWY OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM E3 00 STATE ENCROACHMENT
I PERMIT NO
INDUSTRIAL
WASTE APPRO
OWNERS PERMIT $ z 001-11 CHARGES
CON .'TION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE 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 f SEWER �
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK �(4f �•' Cy; �,�
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PITS) II
AND/OR DRAINFIELD v
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRE BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM TH LEGAL OWNER OF, ND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AS DESC ED ESIDENTIAL OPERTY.
ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑ /p, ) ✓ ,��
SEEP,PITS) ❑ CESSPOOLt4 � d �
VALIDATIO ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK M.O. CASH
Lto 6 1 8 4 NOV 2 5 1 c o 5.00-
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