HomeMy Public PortalAbout6016 KAUFFMAN AVE_Sewer__ 76A 642D-CE808'A-7/76 APPLICATION FOR PERMIT _
+' I SEWER—SEWAGE DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP / SK MAP PROCESSED BY
BUILDING 08 _fC 3 l- 3•-0. �_-=��-�
ADDRESS
CONNECTION DATA
LOCALITY
NEAREST STATION A. DEPTH /_
CROSS ST �_ T l!/
MANHOLE REFERENCE t -�1 J PP
• � V � LOWER
OWNER ,• TYPE OF CONNECTION LENGTH FROM
MAIL / Y CURB P.L M.L TO P.L
ADRESS
D
P C.NO.
CITY GZO&//1Vla -TEL. NO. s CO IMP.NO U JOB NO. -•
e
'LEGAL TRUNK PERMIT NO. ROAD PERMIT NO
DESCRIPTION LOT NO ��-�J a
AFFIDAVIT I WAIVEI [AS[M[MT RECORD. INSTR'NOT DATE
BLOCK TRACT
NO OF SLOGS.
SIZE OF LOT NOW ON LOT HWY ORST WIDENING
USE OF STATE ENCROACHMENT
BUILDINGS PERMIT NO
CONTRACTORp INDUSTRIAL
�[— ^$L WASTE APPROVAL a
ADDRESS 1;38!0 "'���14iU CHARGES
q c� CONNECTION CHARGE FEE
CITY � (� �� TEL NO �/"�-,� /S Q:
STATE LIC REIMBURSEMENT FEE •®
LICENSE NO GLASS
NO I DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE W
HOUSE SEWER CONNECTING TO Q.
PUBLIC SEWER @ N
SEPTIC TANK.SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL a
HOUSE SEWER CONNECTING TO
BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL BLDG LR �/�a/• AND/OR DRAINFIELD -
/ VApa*-TO HOUSE SEWER Com"C)
OVERFLOW SEEPAGE PIT DRAINFIELD CESSPOOL ClDRYWELL [:1EXTN CESSPOOL DRYWELL.MANHOLE
ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM '
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP PIT(S) ❑ CESSPOOLS ❑
OWNER'S Issuance.,Fee $ -100
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AUTHORIZATION TOTAL FEE (Jv AND STATE THAT THE ABOVE IS CORRECT AND.AGREE TO COMPLY
COUNTY ORDINANCES AND STATE LAWS REGULATING
I HAVE AT THIS DATE 'A CONTRACT WITH THE HEREIN NAMED CON. PLUMBING AND'SEWERS.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SEWER LICENSED AS REQUIRELAMTHE
S ANGLES COUNTY A STATE OF
SIGNED THIS DAY OF 19_ CALIFORNIA OR THA LEGAL OWNER OF, INTEND TO
OWNER OR RESIDE IN, THE OVEED RESIDENTIA ROPERTY
OWNERS AGENT SIGNATURE
OF PERMrrT E
ADDRESq
LIDATIO
J� ��/�� /� CK•, .0. CASH
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