HomeMy Public PortalAbout4527 CLOVERLY AVE_Sewer__ °A'42DAPPLICATION . FOR PERMIT 1 .
X-663 ry moN OF BUMDING AND SAFETY SEWER-SEWAGE DISPOSAL
D.parh-w of-Co—iyEay�«s
Cott of La AaQttl�s BUILDING -FRESS
i WM. J. lrOX,COUNTY ENGINMM
CAJMATT D. GRIMM, *ur'T OF BUILDING ALITY
FOR APPLICANT TO M IN REJW
CROSS WT.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT 2 ! MAIL
ADDREEf
SIZE OF LOT I 0 NO. OF BLDGNOW
NOW ON LOT CITY /��'� TEL, R0. FO
{p
USE OF
BUI IROS DISTRICT NO. GROUP I s HR MAY
PG
CONTRACTOR
ADDRM 7 tY
o �yCOxi9�Ox DATA
CITY TEL. N0. Q[ 4 STATION + 1�5� DEPTH
❑ STATE ,� MANHOLE RKFER NCI
REGISTRATION NO. ❑ COUNTY + UPPER
TYPEOF CONNECTION LENGTH FROM /
no. DESCRIPTION OF WORK FEE RB Y.L.TO P
HOUSK SEWER CONNECTING To
PUBLIC SEWER s 3,50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR - CO. IVP. N0. �' JOB. 110.
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT X0.
DISCONNECT ANDABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT N0.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL-DRYWEII WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CAARG[S
CONNECTION CHARGE FEE
OWNIHS PEB341T s 1 0.0
AUTHORIZATION
TOTAL-FEE RZIMBURSIMENT E
.1 HAVE THIS
CONTRACTED
WfT}( HEREIN LNTRACTORTOCONECT THEABOVEDESCRIBEDSTI„ DWLLI
AMOVAL$ DATE IN ECTOR 5 SIGNATURE
TO THE PUB-LIC SEWER
SIGNED THIS SAY OF 19-
NEW HOUSE SEWER
.OWNER 0R CONNECT ADDITIONAL
OWNERS AGE lfT BUILDING ORYORK
SEPTIC TANK,SEEP PIT(t)
ADDRESS AND/OR DRAINFIELb
1 HEREBT ACKNOWLEDGE THAT 1 HAVE READ TH13 APPLICATION CESSP09L[_1DRYYELL❑ .
AXD STATE THAT THE ADOVK If CORRECT AND AGREE TO COMPLY
ITH ALL COUNTY ORDINANCES AND STATK LAWS REGULATING ALTER, REPAIR SEWER OR
LUMBING AND SEWERS. SEWAGE DISP64AL SYMN
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OK
LICENSED AS Rh0U1RED BY LOS AxGELEf COUNTY A11D STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AN THE LEGAL OWNS OF THE ABOVE ABANDON HOUSE SEWKR
DESCRIBED RISIDIZXTIAi.PROPERTY. BACKFILLC TANK?❑
SEp HT CtdfPWLl
SIGNATURE "T
OF PKRYITTEE
WILLIAM 4. FO Couxrr rmGIMMZlR YALMATM
BY
DEPUTY DEPUTY
EY MY
M DEPUTY DEP UTT