HomeMy Public PortalAbout6207 KAUFFMAN AVE_Sewer__ SEBOB 3-87.-` I- •�';
76A842D APPLICATION FOR PERMIT
-,
' COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL �_ J
DEPARTMENT OF COUNTY ENGINEER
° BUILDING AND SAFETY DIVISION FNEAREST
2- -7 JOHN A. LAMBIE. COUNTY ENGINEER
COLEMAN W. JENKINS. SUPT. OF BUILDING
/LCL (,
FOR APPLICANT TO FILL IN LEGAL
DESCRIPTION LOT NO OWNER
MAI
BLOCK TRACT AD_
DR S�
NO OF BLDGS 781
..•� _
SIZE OF LOT NOW ON LOT CITY T NO.,. L��
USE OF
BUILDINGS DISTRICT NO I GROUP MAP E1,911 BY
CONTRACTOR BK PG�/ 7� ,rL�
ADDRESS CONNECTION DATA
CITY EL NO / STATION fi� Q DEPTH
STATE • LIC MANHOLE REFERENCE j 4. � A1�/ UPPER
LICENSE NO„ 6LA'SS / LOWER
NO DESCRIPTION OF WORK FEE TYPE OF TION LENGTH FROM r
HOUSE SEWER CONNECTING TO Y URB P L M L TOP L. d
PUBLIC SEWER @ $5 00
SEPTIC TANK,SEEPAGE PIT OR Z P.0 NO O
PITS AND/OR DRAINFIELD @ SIO 00 CO IMP. NO JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO I
PRIVATE DISPOSAL SYSTEM @ $3 00 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I wAIVEE I EASEMENT RECORD INSTR NO DATE I...
WORK TO HOUSE SEWER @ $3 00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN CESSPOOL DRYWELL MANHOLE @ $500
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING N
SEWER OR DISPOSAL SYSTEM @ S3 00 STATE ENCROACHMENT
' t6? n1 PERMIT NO
(J INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION TOTAL FEE
d 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 -- DAY OF 1 -
OWNER OR NEW HOUSE SEWER
OWNERS AGEN ONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIO 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 ❑ _
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNOR HA AM THE LE L OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IIN,A TT
HE AB DESCRIB RESIDENTIAL OPERTY ABANDON HOUSE SEWER
SIGNATURE
BACKFILL SEPTIC TANKS ❑
OF PERMrr?4 SEEP PIT(S) ❑ CESSPOOLS ❑
,�ALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CKd/�J M 0 CASH