HomeMy Public PortalAbout6031 KAUFFMAN AVE_Sewer__ 76A 642D - CE808 - 9/73 APPLICA 0 I FOR PE 9 1 I
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL. LJ
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS �T✓"
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL /
DESCRIPTION' LOT NO. ( . / OWNER
`� MAIL /
BLOCK TRACT �.� ADDRESS 9G
NO. OF BLDGS,
SIZE OF LOT NOW ON LOT C17Y TEL. NO.
USE OF /- DISTRICT NO. GROUP MAP pROC SED BY
BUILDINGS i BK pG
CONTRACTOR �. �J��>
ADDRESS C�/� �JI /� m (���tG� CONNECTION DATA
CITY A(fJlwl •STA �J�J'j,.� TEL, NO.ZJLICu�� jSJ STATION / DEPTH
L CENSE NO:,�pL.L7:J �' CLA55 �~ / MANHOLE REFERENCE 1��! "3� �, LOWER^�
NO. DESCRIPTION OF WORK FEE TYPE OF O TION LENGTH FROM
/ HOUSE SEWER CONNECTING TO CCURB
Y. ^ P.L. M.L.TO P.L.
PUBLIC SEWER @ $7.00 �
SEPTIC TANK.SEEPAGE PIT OR / 30 ,6 0 ,6 P,C.NO,
PITS AND/OR DRAINFIELD @ $IO.00
CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT N0. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 i1
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIV ERI EASEMENT RECORD.INSTR.NO. DATE >
WORK TO HOUSE SEWER @ $3.00 O:
OVERFLOW SEEPAGE PIT.DRAINFIELD CD
TN..CESSPOO
A 0 $5.00 HWY.OR ST.WIDENIN �v�7 ��. p_+
ALTER.REPAfR ORR ABANDON
N HOUSE
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT ..i OI—
MANHOLE !� $7.00 PERMIT NO. W
INDUSTRIAL N
WASTE APPROVAL �
CHARGES —
OWNER'SPERMIT $ 3 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE CaCC
i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW �. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF ���Y�n 1$�C \
OWNER OR NEW HOUSE SEWER ��%may ?, ''-
OWNERS AGENT-C"� ✓T�� A CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
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
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM,
CALIFC67NIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO - DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENT PROPERTY.
/ ABANDON HOUSE SEWER '.
SIGNATURE
OF PER MTTTEE <' /`�T / 6A ( BACKFILL S C
.s'? EssPooLs
VA ATION CK. M.O. CASH
ii
5 _9)4r APR .10 1 0 U I U.0 0 �L