HomeMy Public PortalAbout6051 KAUFFMAN AVE_Sewer__ CEBOB3-B2 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPO
78A842D SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS i
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COLEMAN W. JENKINS. SUPT OF BUILDING
LOCALITY r� V�
NEAREST
FOR APPLIC T TO FILL IN `ROSS ST. /Q�/►
LEGAL //-! D�T /•�
DESCRIPTION LOT NO / OWNER
MAIL w Y-
BLOCK TRACT ADDRESS /�//l
NO OF BLDG
SIZE OF LOT NOW ON LOT CITY TEL NO.
USE OF ��� p DISTRICT NO, GROUPJ MAP 6 PROCESSED BY
BUILDINGS //
BK PG
CONTRACTOR Q V �� /
VN r . vw. r. -
ADDRESS CONNECTION DATA
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I.J I t,r ib t'• STATION DEPTH
CITY TEL NO _ p
STATE [, r it:� LIC•H• J �- / PP
GLA S,, MANHOLE REFERENCE
LICENSE NO, •�
NO .DESCRIPTION F4IWORK FE '�I r I-r•�L• TYPE OF TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P.L. M.L TOP L d
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR PC.NO O
PITS AND/OR GRAINFIELD @ f10.00
CO IMP. NO �� JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $3 00 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVEq [ASe .l RECORD.INSTR NO. DATE 0
WORK TO HOUSE SEWER @ $3 00 (J
OVERFLOW SEEPAGE PIT.DRAINFIELD W
EXTN.CESSPOOL.DRYWELL MANHOLE @ $5 00 d
ALTER.REPAIR OR ABANDON HOUSE HWY OR ST WIDENING H
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS - PERMIT s 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNEC THE ABOVE DESCRIBED EXISTING DWELL NG
TO THE PUBLIC SE �� APPROVALS DAT I�ECTOR ')IG NATO RE
SIGNED THIS DAY OF 1
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
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 15 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
LICENSEDAS REQU ED LOS A LES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR AT 1 THE GAL WNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. TH ABO D CRIB RES EN L PROPE RT ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS Cl •� j ('
OF PERMfTTEE SEEP PIT(S) ❑ CESSPOOLSNJ
I G T
VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK
M.0 CASH
[ C-, .5 b 3 JAN1.0 i 1 '0 Q`0 M d
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