HomeMy Public PortalAbout4533 CLOVERLY AVE_Sewer__ APPLICATION FOR PERMIT
COUNTY OF LOS AHGII. SEWEREWAGE DISPMAL:-.-l
D2P"TDWlfi OF COUNTY Farms
B=MG AND SAE= D MQN BUILDING
JOHN b T.XvwrRADDRESS
C"MAn D. �FlLL". of l _ - -
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
LEGAL
DESCRIPTION LOT NO. / OWNER
BLOCK TRACT MAIL jV
ADDRESS
NO.OF BL.DGS.
SIZE OF LOT NOW OR LOT CrTT Tx L,
USE OF
BUILDING DISTRICT NO. GROUP IAP
CONTRACTOR B
ADDit£dS v COMEGTI02f D14TA
CITY TIL No. STA-n
om
DEPTH
REGISTRATION NO. Fr'ITAIWIlf
MANHOLE of RwCE PPER
NO. D5SCRIPTION OF WOTZX FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER TY
Ot LL�EN1GTH FitOR
SEPTIC TAl�XNK.SEEPAGE PIT OR U P.L. �.L TO PT PITS AND/OR DRAINFIELD 5.00
OVERFLOW SEEPAGE PIT,DRAINFI LD
EZTl1. CESSP00 ----'L MANHOLE 2.00
HOUSE SEWER CONNECTING TO P.C.110.
PRIVATE DISPOSAL SYSTEM 1.00 CO.IMP.NO. JOB X0.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER 1.00 TRUNK PERMIT N0. ROAD PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL STSfEY 41.010 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OW EES PgmmaT 00 coN11ECT10IL CHARGi FEE
AUTSORMATION T6-T), p7t- — REI MBURSEY]ENT FES
I RAVE AT THIS DATE A-CONTRACT LITH-Tfl EREIN NAMED-COX• �-
TRAC7'gR 7O CONNECT- THE ABOVE DESCRIBED ELISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATU
TO THY PUBLIC SE1YIE.
SIGNED THIS 10 DAY OF -Fre Y, ~1 NEW HOUSE SEWER - 8 -
p�?IER OR �� 1 - - CONNECT ADDITIONAL- -
ERS AGEIIT BUILDING OR WORK
ADD - .�J - +�fV�I -dEfT C-TANI1,SEELP PIT(S)---
AN OR DRAW? b _
I HEREBY ACKNOWLEDGE THAT I HA READ THIS APPLICATIONSTA ;
W17H ALLAND Y CO w 61rulcl ANDCT STATED AGREE TO-COMPLT-LAWS REGULATING -CESSPOOL DR`YWELL
PLUMBING AND SEWERS, ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTITT-TH71T I AI PROPERLY- REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED ST LDS ANGELES! COUNTY AND TE 0 ABANDON HOUSE SEWER
CA LIFO OR_TI(AT I TH SALFT
DESCAIB BACKFILL SE C TANKS
,GNA.T� / SEEP.PITS CESSPOOLS '
OF PEA�I -
m. rompm
VALIDATIOIi,--, ROBER�r A. WOOS
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