HomeMy Public PortalAbout6043 KAUFFMAN AVE_Sewer__ 78A842D
CE808 8.59 APPLICA10N FO PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engineer �-+
CASSATT D. GRIFFIN, Supt of Building LOCALITY / L
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. J
LEGAL y OWNER /
DESCRIPTION LOT NO. TIS
BLOCK, TRACT MAILi�o ADDRESS
NO.OF BLDGs
SIZE OF LOT J NOW ON LOT CITY TEL. N0.
USE OF
BUILDINGS DISTRICT N0. GROUP MAP PROCESSED BY
_ � � BK ��
CONTRACTO ;
ADDRESS CONNECTION DATA
CITYLr/, EL.N0. STATION L� DEPTH
� l _
STATE MANHOLE REFERENCE ��J•`
REGISTRATION NO. COUNTY T 7 . LOWER
NO. DESCRIPTION OF WORK FEE
i HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE ONNECTiION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
ITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD _
EXTN..CESSPOOL DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO { P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. �! JOB NO.
CONNECT ADDITIONAL BLDG.OR '�
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT N0. 0
SEWER OR DIISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT •-
PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'.S PERMIT $ 2 00 CONNECTION CHARGE•FEE -
AUTHORIZATION I TOTAL FEE (j REIMBURSEMENT FEE
CON-
TRACTOR TO CIONNE T THE ABOVE DESCRIBED EXIISTINGDATE A CONTRACT WITH THE HEREINADWELLIING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS A OF 19Z NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT - BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING pLTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 ARI PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY OS ANGELES CO D STATE OF ABANDON HOUSE SEWER A
CALIFORNIA OR THAT 1 HE LEGAL W R OF THE ABOVE
DESCRIBED RESIDENTIA ROP TY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PITS) ❑ CESSPOOLS ❑� / bY! uj,/!c�' f��
OF PERMITTEE
®P LMATION ROBERT .4. WOOD
Ct:. M.o. CASH SUPERVISING MECHANICAL ENGINEER