HomeMy Public PortalAbout6203 KAUFFMAN AVE_Sewer__ • R � � ,
76A 642Q' - CE806,,- 9/73 APPLICATION POR PERMIT.
COUNTY OF'SOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF-COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ��
ADDRESS 14.A AM
LOCALITYFAR APPLICANT TO FILL IN NEAREST � e „jGROSS STLEGAL /) AA)DESCRIPTION LOT NO. OWNERVMAIL /�IDO BLOCK TRACT ADDRESSNO OF BLDGS Q'�SIZE OF LOT NOW ON LOT CITY wC O TEL. NO.
USE OF
BUILDINGS f
TRICT NO. GROUP MAP. PROESSED BY
//�J BKP(U�CONTRACTOR DIV” )9 e c '-{.�8 1T-3 / 7�1 ADDRESS I CONNECTION,^ ATION ,(,, �' DEPTH
CITY Q� 1^TEL NO. �p� c[
STATE 944-'FS-7 G ASS �— JO MANHOLE REFERENCE + "-A/� UPPER
LICENSE NO, �
NO. DESCRIPTION OF WORK FEE TYPE OF TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M L.TO P.L.
PUBLIC SEWER 0 $7.00
P.C.NO.
SEPTIC TANK.SEEPAGE PIT ORCO.IMP NO. JOB NO.
,
PITS AND/OR DRAINFIELD @ f10 00
23.3
Z,
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO.�
PRIVATE DISPOSAL SYSTEM @ S300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIY[[ [A8[Y[xT RECORD,INSTR NO. DATE
WORK TO HOUSE SEWER ® $300 d
OVERFLOW SEEPAGE PIT,DRAINFIELD C_').
EXTN CESSPOOL DRYWELL 5500
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST WIDENING �
SEWER OR DISPOSAL SYSTEM $300 CD
STATE ENCROACHMENT
MANHOLE $7.0 PERMIT NO -W
INDUSTRIAL
WASTE APPROVAL } N
CHARGES Z
OWNER'S PERMIT. s 00
AUTHORIZATION TOTAL FEE 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 APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ ,
OWNER OR NEW HOUSE SEWER -
OWNERS AGENT / /
CONNECT ADDITIONAL /Vl-3a"J
ADDRESS - BUILDING OR WORK
SEPTIC TANK.SEEP.PIT(S)
I HEREBY 'ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING '
PLUMBING AND SEWERS CESSPOOL ❑ DRYWEL'L-❑
IHEREBY CERTIFY AT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUI D BY LOS ANGLES.COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFC69N IA OR TH 1• M THE EGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A VE ESCRIB D ESI TIAL PRObERTY
ABANDON HOUSE SEWER
SIGNATURE
OF PEQMTTTE BACKFILL SEPTIC TANKS ❑ -
SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATIONCK. M•O• CASH
WORKERS COMPENSA1"I� '
'fJLIClI I-IOI_DER: � 7 5 .9�1 � 3�, g D
Q 1' C)
'CL.ICY NUMBER: 27