HomeMy Public PortalAbout6103 KAUFFMAN AVE_Sewer__ t
76A642D
' 3-64 APPLICATION FOR PERMIT
6A64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION . BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS �Q
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAREST
FOR APPL CANT TO FILL CR05S 5T
LEGAL
DESCRIPTION LOT Ngrj J OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS. >� ��,,pp� �
SIZE OF LOT NOW ON LOT CITY JX, 'e/VTEL NO.
USE OF DISTRICT NO GROUP MAP
PROCE§#D BY
BUILDINGS
'1 BK PG )
CONTRACTOR
ADDRESS G CO CTION DATA
CITY TEL _ STATION DEPTH -
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. B COUNTY LOWER
NO, DESCRIPTION OF WOAK FEE TYPE OF CONNECTION LE
HOUSE SEWER CONNECTING TO Y, CURB P.L. .L.TO P.L.
PUBLIC SEWER $5.00
P.C.NO, }.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND
/ORDRAINFIELD $1000 CO.IMP. NO. JOB NO, d
HOUSE SEWER CONNECTING TO TRUNK PERMIT IN ROAD PERMIT NO. O
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WA [R 1 [AS[61[NT RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 - O
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN,CESSPOOL,DRYWELL,MANHOLE @ $5.00 V
ALTER,REPAIR OR ABANDON HOUSE HWY OR .'WIDENING LU
d
5EWER OR DISPO L SYSTEM ,-y@ $300 STATE CROACH MENT - N
PERMI NO Z
a U tJ
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ z oo -
AUTHORIZATION TOTAL FEE 1 `r CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAYOF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(5)
1 HEREBY ACKNOWLEDGE THAT 1 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 ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNT AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB V DESCRIBED RFri/$CJENT ROPERTY ABANDON HOUSE SEWER
SIGNATURE UCS{ ►w BACKFILL SEPTIC TANKS ❑
SIGNATURE
PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
CK M o ��C—AS�H'j SUPERVISING MECHANICAL ENGINEER
L 13 -9 5-0'--,. Pati, 4 1' 0 D 5.0 0