HomeMy Public PortalAbout6206 KAUFFMAN AVE_Sewer__ ,
76A64 2D 0-63- APPLICATION FOR -PER IT
A64
COUNTY OF LOS ANGELES SEWER-SEWAGF7p4SPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BU ILID IN Z
JOHN A. LAMBIE, County Engineer ADDRE '^
WILLIAM A. JENSEN, Sup't of Building
LOCALITY y
NEAREST
FOR APPLICANT TO FILLCROSS
LEGAL
DESCRIPTION LOT NO OWNE
MAIL
BLOCK TRACT ADDRESS
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY .TEL.USE OF
BUILDING DISTRICT NO GROUP MAP P PROCESSED BY
BK
CONTRACTOR �.`�/ �
t
ADDRESS �. �� CONNECTION DATA
CITY TEL STATION DEPTH
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TATE MANHOLE REFERENCE REGISTRATION NO El COUNT Y LOWER
NO DESCRIPTION OF WORK FEE TY E F CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y RB P L M L.TO P.L.
PUBLIC SEWER @ $5 00 ,,..
SEPTIC TANK,SEEPAGE PIT OR P C.NO O
JOB NO.
PITS AND/,OR DRAINFIELD @ $10 OO CO IM NO 6 �•''
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO ix
PRIVATE DISPOSAL SYSTEM ' @ $3 00 ^
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NOS DATE G
WORK TO HOUSE SEWER @ $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD Y.1
EXTN CESSPOOL.DRYWELL,MA N HOLE @ $5.00
ALTER REPAIR OR ABANDON HOUSE ' HWY OR ST WIDENING H
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE'ENCROACH MENT
PERMIT NO
INDUSTRIAL
WASTE APPR AL
OWNERS PERMIT S 2 00 CHARGES
AUTHORIZATION TOTAL FEE 00 CONNECTION CHARGE FEE
,
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBE XISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK {4r
ADDRESS SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO, COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS EGULATING
PLUMBING AND SEWE CESSPOOL ❑ DRYW ELL ❑
I HEREBY CERT TH I AM PROPERe
TER ANDOR ALTER,REPy41R,SEWER ORLICENSED AS R DIRE BY LOS ANGL AN STATE OF SEWAGE-0Q1$P05'A_'L SYSTEM
CALIFORNIA O THAT AM THE LEGA A INTEND TO DISCONNECT PLUG ANDRESIDEIN, E A E DESCRIBED EERTY ABANDON HOUSE SEWER
SIGNATURE �! BACKFILL SEPTIC TANKS ❑
OF PERM I E ❑
SEEP.PIT(S) ❑ CESSPOOLS
(
VALIDATION ROBERT.A. WOOD SUPERVISING MECHANICAL ENGINEER
CK M O, CASH
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