HomeMy Public PortalAbout6231 KAUFFMAN AVE_Sewer__ /-3.3 A, �� ���✓
c GOO-° APPLICATION FOR PERMIT
rane-e-as COUNTY OF LOS ANGELES
- SEWER=SEWAGE. DISPOSAL
`DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County'Fagineer ADDRESS
CASSATT D. GRIFFIN, Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO FELL IN CROSS ST.
LEGALOWNER
DESCRIPTION LOT NO.
BLOCK TRACT NAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CI TEL.N0.
USE OF
BUILDINGS i DISTRICT NO. GROUP MAP PR SSED
BK P6
CONTRACTO i�
ADDRESS r CONNECTION DATA
CI p6wlfATEL.NO. _ STATION' DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION N0. 1 B SCOUTATE LOWER
NO. DESCRIPT10N OF WORK FEE `
HOUSE'SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 pE OF CONNECTION FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TLENGTIH P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE Q $2.00 r
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
SEWER OR DISPOSAL SYSTEM HOUSE $1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL -
WASTE APPROVAL -
CHARGES
OWNER�.S PERNIIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE &-C) REIMBURSEMENT FEE
I HAVE-AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE - INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF ]9_ NEW HOUSE SEWER
OWNER ORJt/� CONNECT ADDITIONAL /q_ � /,k���,e �•�
OWNERS AGENT �Il VU BUILDING OR WORK
SEPTIC TANK,SEEP,PITS)
ADDRESS _ AND/OR DRAINFIELD
I -HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES_ AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING, AND SEWERS. I SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND.
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I THE GAL OWNER 7HE ABOVE
DESCRIBED RESID TIAL PER BACKFILL SEPTIC TANKS❑
SEEP.PITS CESSPOOLS❑
SIGNATURE
OF PERMITTE
®: VALIDATION ROBERT A..WOOD
H.p, c"m SUPSRVI81NG MECHANICAL HNGIN=R
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