HomeMy Public PortalAbout6201 KAUFFMAN AVE_Sewer__ J
CEBOE 2'70 'APPLICATI - R RMI
76A 642D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS. SUPT OF BUILDING
LOCALITY V 1
NEAREST
OR APPLICANTTO FILL IN cRoss sr.
(PRINT OR TYPE ONLY) 064
LEGAL
DESCRIPTION LOT NO, OWNER
MAIL
BLOCK TRACT ADDRESS
SIZE OF LOT NOW OON LOT CITY t TEL
USE OF DISTRICTNO GROUP I CLASS MAP PROC SSED BY
BUILDINGS
BK PS
CONTRACTOR. /
ADDRESS . 7
` CONNECTION DATA
�J_� '}'1 u STATION � � DEPTH
CITY TEL N a� v l
STATE LIC e MANHOLE REFERENCE IIUPP
LICENSE.NO CLASS LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CO CTION LENGTH FROM
HOUSE SEWER CONNECTING TO /j/1 Y R P.L. M L TO P.L
PUBLIC SEWER a $5 00 [/.C!
SEPTIC TANK.SEEPAGE PIT OR P C NO
PITS AND/OR DRAINFIELD $1000 CO IMP NO !rr .10B NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO /g'+�) >"
PRIVATE DISPOSAL SYSTEM @ $3 00 '�V CL
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIY[R "[I15[M[N1 RECORD INSTR IN DATE O
WORK TO HOUSE SEWER @ $300 V
OVERFLOW SEEPAGE PIT.DRAINFIELD _
EXTN.CESSPOOL DRYWELL MANHOLE 0-$5 00 HWY OR ST WIDENING O
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT - u
PERMIT NO W
a
INDUSTRIAL N
WASTE APPROVAL Z
CHARGES
OWNERSPERMIT S Oo
AUTHORIZATION TOTAL FEE v ®i5 CONNECTION CHARGE FEE
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 SEWER. A'PPROV'ALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS gggDA��'Y O 19_
OWNER OR am .. NEW HOUSE SEWER /
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT, I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT 15)
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 C_ TY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I M THE LEGAL OW R OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV DESCRIBED RESID T AL PROPERTY ABANDON HOUSE SEWER
SIGNATURE
OF PER MITTE -SBKLL� 6 -7MFE-"4*r`eSJE} CESSPOOLS 7
VALIDATION
Ylo�
JACK'R. ALLEN
CK M.o CASH SUPERVISING MECHANICAL ENGINEER,
L c -2 8.7--D AF11 4 i' G 'a