HomeMy Public PortalAbout6249 KAUFFMAN AVE_Sewer__ 76A 6420 -_CtI368 - 9/73 - APPLICATION R PERMI _
• COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FCRQSS
DING /� .n' ( `
ESS "T 'y �^
LITY
EST
FOR APPLICANT TO FILL IN ST
LEGAL
DESCRIPTION LOT NO. ♦ OWNER Z-- AD• I'1
MAIL G Z 4 p
BLOCK TRACT ADDRESS (l/ Lr G
NO. BLDG$. 7-4'
r
SIZE OF LOT NO ON LOT CITY Nn�7/T� ` 1 / L. NO.
USE OF DISTRICT NO. GROUP MAP PRQCES ED BY
BUILDINGS _ BK PG
CONTRACTOR
ADDRESS vA7 T/V L t�4141)/, -!�'rL CONNECTION DATA
CITY S Q �Ok ( ,TEL NO.li`�1—/ �J �� STATION ,,,���/JJ DEPTH -
STATE 7 OQ / C16 GLASS C—'3 Lic MANHOLE REFERENCE ��O 6�� �' LOWER
LICENSE NO. (�
NO. DESCRIPTION OF WORK FEE TYPE OFC TION LENGTH FROM��
HOUSE SEWER CONNECTING TO �\ Y. CURB" P.L. M.L.TO P.L.
PUBLIC SEWER $7.00 (J
SEPTIC TANK SEEPAGE PIT OR 3 -Z�, 10.NO.
?
PITS AND/OR DRAINFIELD @ sl0 o0 CO.IMP.NO. `J JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM S300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER [AS[M[NT RECORD.INSTR NO. DATE
WORK TO HOUSE SEWER ® $3.00
CL
OVERFLOW SEEPAGE PIT,DRAINFIELD G
EXTN.CES.P.OL,DRYWELL s3 DO V
ALTER.REPAIR OR ABANDON HOUSEHWY.OR ST WIDENING C
SEWER OR DISPOSAL SYSTEM $300
STATE ENCROACHMENT C)
MANHOLE $7.00 PERMIT NO V
INDUSTRIAL LV
a
- o WASTE APPROVAL C/7
PERMIT
CHARGES
'OWNER'S s
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON, REIMBURSEMENT FEE _
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING T
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF------- 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGE C CONNECT ADDITIONAL
5
ADDRESS { - � *dln BUILDING OR WORK
SEPTIC TANKSEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIOAND/OR DRAI NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
N
LC
AND SEWERS CESSPOOL ❑ DRYWELL ❑
CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR
AS REQUIREDBVLOS ANGLES-COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
A OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
THE A E SCR B D RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑ITT ❑
SEEP PIT(S) ❑ CESSPOOLS
VALIDATION M.O. CASH
3.5 �8 MAY 18 1 .�9 ® 1 5.0 0 asa