HomeMy Public PortalAbout4804 CLOVERLY AVE_Sewer__ CES08.8 APPLICATION FOR PERMIT'
anoe-s-ss COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL ,
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
CASSATI D. GRIFFIN, Sup't of Building LOCALITY
NEAREST d
FO PPILC T TO FILL IN fCROSS ST.
LEGALv
DESCRIPTIO LO N0. OWNER
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT I CITY TEL. NO.
USE OF ..
BUILDINGS ' DISTRICT NO. GROUP^ MAP BK P6 PROCESSED BY
CONTRACTOR /10
ADDRESS ` C NNECTION DATA
CITY TEL.NO. STATION 0 DEPTH
STATE MANHOLE REFERENCE ry
REGISTRATION N0. / / ,� �i ! ® COUNTY �T LOWER
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
J' ��
I PUBLIC SEWER @ $3.00 J TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK, SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EX TN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO 9 P.C.NO.
i PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. S JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL -
WASTE APPROVAL
CHARGES
OAR'S PERMIT 5 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 5 00 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVAL DA7E INSPEC70 SI6tATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ..R'S�>
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF Ig_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP, PIT(S)
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. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL ROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PIT(S) CESSPOOLS❑
OF PERMITTEE
®P VALIDATION ROBERT A.WOOD
M.p. CASH SUPERVISING MECHANICAL ENGINEER
( AU0 6 5 5 r4'L t1y 18 1 O A 5-0,0
It�GGG%�ry