HomeMy Public PortalAbout6156 KAUFFMAN AVE_Sewer__ APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 6156 North Kauffman :en
COLEMAN W. JENKINS. S.UP'T OF BUILDING Temple City
Locnurr
F R APPLICANT TO FILL IN NEAREST
(PRINT OR TYPE ONLY) CROSS ST.
FBUILDINGS
ON LOT NO OWNER John Marshall
MAIL
TRACT ADDRESS 1010 East Las TunasOT NOWNO OON LOTS CITY San Gabriel TEL NO At 6
DISTRICT NO. GROUP CLASS MAP PROCESSED BY
BK pG
CONTRACTOR Owen Bros. Plumbing,Ine. 7S
ADDRESS 4265 No. Baldwin Ave. CONNECTION DATA
C1TYEl Monte 91731 TEL NO. 443-0078 STATION DEPTH
STATEGLASS C36—sc2O MANHOLE REFERENCE UPPER
7
LICENSE NO 231 (41 LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P•L. M L TO P.L.
PUBLIC SEWER $S 00 _
SEPTIC TANK SEEPAGE PIT OR P C NO.
PITS AND/OR DRAINFIELD SIOOO CO IMP. NO JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO d
.
PRIVATE DISPOSAL SYSTEM ® $300 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVIR IASIMINT RECORD.INSTR NODATE U
WORK TO HOUSE SEWER @ S300
OVERFLOW SEEPAGE PIT.DRAINFIELD yi
EXTN CESSPOOL.DRYWELL.MANHOLE $3 00 HWV OR ST.WIDENING O
ALTER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM $3 00 STATE ENCROACHMENT W
PERMIT NO
CL
INDUSTRIAL N
WASTE APPROVAL Z
OWNERCHARGES
S PERMIT 4 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL- FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
4
F2 _
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL [IDRYWELL [31 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY"AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A VE SCRIBED
OF PERMITTEE R DENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
SEEP PIT'S
❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
CK M O cnsH SUPERVISING MECHANICAL ENGINEER
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