HomeMy Public PortalAbout6003 KAUFFMAN AVE_Sewer__ 76A642D APPLICATION FOR PER-MIT
6 . _ - °
&E-663 11.55
-DIVISION OF BUILDING; AND SAFETY SEWER-SEWAGE 'D ISPOSA�L io
Department of County Engineer
r County of Los' Angeles BUILDING -
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS (! V
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITYNEAREST FOR APPLICANT TO FILL IN - CROSS ST. p
LEGAL - r ��; OWNER - L&' ,_ '
DESCRIPTION LOT N0. _
BLOCK TRACT '/ - ADDRESSMAIL
) -
NO. OF BLDGS. I CITY _ TEL. N0. Z 7
SIZE OF LOT -NOW ON LOT
USE OF
BUILDINGS DISTR"IC'T.NO. GROUP MAP '
- _
� BK PG" -
CONTRACTOR _C'
IleADDRESSj.3 CONNECTION'DATA
STATION DEPTH
CITY 9 TEL. N /�A�"' ,f L'
' /v-,/ MANHOLE REFERENCE - ,
tK STATE LOW
REGISTRATIO N0. ❑ COUNTY 'NO. DESCRIPTION OF W K FEE
HOUSE SEWER CONNECTING TO (TYPE OFC ION LENGTH FROM
PUBLIC SEWER @ $3.50 O •l RB ,�4� M.L.TO P.L._
SEPTIC TANK,SEEPAGE PIT OR - - -
PITS AND/OR DRAINFIELD Q $3.00 -
OVERFLOW SEEPAGE PIT, DRAINFIELD - P. C. N0.
EXTN.,CESSPOOL,DRYWELL,M AN HO LE Q $2.00 CO. IMP. NO. �(� �/} JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1.00 _TRUNK PERMIT NO. ROAD PERMIT N
CONNECT ADDITIONAL BLDG,OR STATE ENCROACHMENT
WORK TO HOUSE SEWER - Q $I.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL "
CHARGES
CONNECTION.CHARGE FEE
OWNER'S PERMIT 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL-FEE
I HAVE AT THIS DATE•A CONTRACT WITH THE IE -IN AMED coN- APPROVALS DATE_ INSPECTO R'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING _ ^m
TO THE PUBLIC SEWER. - 1 NEW HOUSE SEWER
SIGNED THISAL-DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS-AGEN 00, SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD - ••
I HEREBY ACKNOWLEDGE THAT I HAVE THIS APPLICATION CESSPOOL❑ DRYWELL EI
AND STATE THAT'THE ABOVE IS CORRECT 'AND-AGREE TO COMPLY
WITHALL 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 DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES 'COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT, I AM THE LEGAL OWNER OF THE BO VE '
SCRIBED RES D NTIA 6PERTY. KFILL SEPTIC TANKS❑
�14tr�•GG.C..V'
SI U .. Os: P.PITS) ❑ CESSPOOLS
1 ,
F PERMITTE
JOHN A. LAMBIE, COUNTY ENG EER VALIDATION. - ROBERT A. WOOD, CHIEF PLeG. INSPECTOR
CK. pi. 0.
5 s ,- APR?3'' -4 4,50