HomeMy Public PortalAbout6013 KAUFFMAN AVE_Sewer__ . ® ®® (q_/per,
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5&E-663 12-54
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County-of Los Angeles BUILDING
WM. J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN, SUPT of BUILDING LOCALITY
FOR APPLICANT TO FIL IN NEAREST r
CROSS ST.
LEGAL
DESCRIPTION LOT N•Q. OWNER /` j v,.- •✓` /�
BLOCK TRACT /� MAIL b 67
ADDRESS
ap-lrSIZE OF LOT
N 0. OFBLDGS.
NOW ON LOT CITY TEL. NO.
USE OF
BU ILDINGS� ,, ( DISTRICT NO. GROUP MAP
.^ BK PG
CONTRACTOR //'� '7�
ADDRESS r +y/ l CONNECTION DATA
CISTATION
.Y _ �j w '! C {c,, DEPTH 9
T TEL. NO.
/ ❑ STATE - fiANHOLE REFERENCE
REGISTR LION NO. ❑ COUNTY �i"Y' C' UPPER &[ER
v Y TYPE :CURB ,ECTIOP.L. M.L. FROM
J
NO. DESCRIPTION OF WORK FEE - _
HOUSE SEWER CONNECTING TO
PUBLIC SEWER g $ 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM „ 1.00
CONNECT ADDITIONAL BLDG._`- // J�, CO. IMP. NO. �• JOB. NO.
WORK TO HOUSE SEWER ,N,rf'L. 1,00 y („f" _ / �64,
ALTER OR REPAIR EXISTING o'
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFiELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 ARGES�
PERMIT CONNECTION CHARGE FEE ter" r
OWNERS S 1 00 !
AUTHORIZATION TOTAL FEE � REIMBURSEMENT FEE
TRACTORHAVE T TOS CONNECTDATE ONTRTHEA ABOVECTED WDESCR BEDITH THE HEREIEXISTIINGNAMED
DWELLIINC APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER --
eAq�, S NEW HOUSE SEWER
SIGNED THIS_ DAY OA�F^^
OWNER OR G`� s CONNECT ADDITIONAL
OWNERS AGENT " / (( BUILDING OR WORK
ADDRESS SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE Ail THIS APPLICATION CESSPOOL❑ DRYWELL❑.
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
I HEREBY CERTIFY THAT I AM PROPE<;,LY REGISTERED AND/OR
LICENSED AS REQUIR LOS ANGE S��WNERY OF THE AND STATE
ABOVE ABANDON
ECT HOUSE SEWER
PLUG AND
CALIFORNIA OR THAT--A A M, ?H,Er LE04
DESCRIBED RESIDENTIAL R/p.FrTY, BACKFILL S�
4 ,. �' SEPyP3S=pirl✓� CESSPOOLS
SIGNATURE - -
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
In
BY BY
DEPUTY 4 DEPUTY
BY BY
r
0 DEPUTY y. DEPUTY