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Home My Public Portal About4828 CLOVERLY AVE_Sewer__ 768083 62 76A842D APPLICATION FOR PERMI i COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A LAMBIE County Engineer ADDRESS WILLIAM A JENSEN Sup t of Building c LOCALITY NEAREST FOR APPLICANT TO FILL IN IR IS ST LEGAL DESCRIPTION LOT NO OWNER MAIL BLOCK TRACT ADDRESS NO OF BLDGS SIZE OF LOT NOW ON LOT CITY TEL NO USE OF BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY BK PG f CONTRACTOR ADDR SS C EC -I DATA CIT 17 TEL NO �% �,STATE E 5T ION , DEPTH REGISTRATION NO 6 �(O COUNTY MANHOLE REFERENCE OWER NO DESCRIPTION OF W RK FEE TYPE OF CONN T LENGTH FROM HOUSE SEWER CONNECTING TO Y C PL M L TO P L O PUBLIC SEWER a 55 00 SEPTIC TANK SEEPAGE PIT OR CO IMP NO L J C NO V PITS ANO/OR DRAINFIELD @ 51000 JOB NO HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO O PRIVATE DISPOSAL SYSTEM @ $3 00 ✓✓✓ 0 CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVEN CASEXENT RECORD INSTR NO DATE WORK TO HOUSE SEWER @ $300 OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE @ $500 ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT $ z o0�) AUTHORIZATION TOTAL FEE aV CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER !f OWNERS AGENT_ CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK SEEP PIT(S) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANO/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM 7 LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE A E D RESIDENT{. ROP`TY ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ElOF PERMITT SEEP PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT A WOOD CK M O CASH SUPERVISING MECHANICAL ENGINEER LltiJO 8 4 6 2\ DEC J 4 1 0 7.0 Qr a 760083 62 78A642D APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A LAMBIE County Engineer ADDRESS WILLIAM A JENSEN Sup t of Buildmg LOCALITY NEAREST FOR APPLICANT TO FILL IN 7RDB5 5T LEGAL DESCRIPTION LOT NO OWNER MAIL BLOCK TRACT ADDRESS NO OF BLDGS SIZE OF LOT NOW ON LOT CITY TEL NO USE OF c DISTRICT NPG O GROUP MAP SED BY BUILDINGS BK ) CONTRACTOR `) 4 J0 ADORE CONNECTION DATA S TION DEPTH CIT EL N STATE MANHOLE REFERENCE REGISTRATION NO ` pc. COUNTY OWER NO DESCRIPTION OF WORK FEE ! TYPE OF CONNE TI LENGTH FROM HOUSE SEWER CONNECTING TO Y CU M L TO P L PUBLIC SEWER @ $5 00 V SEPTIC TANK SEEPAGE PIT OR P C NO V PITS AND/OR DRAINFIELD @ $10 00 CO IMP NO JOB NO V HOUSE SEWER CONNECTING TO - TRUNK PERMIT NO ROAD PERMIT NO O PRIVATE DISPOSAL SYSTEM �� 83 00 CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER I EASEMENT RECORD INSTR NO DATE WORK TO HOUSE SEWER @ $300 OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE @ $500 ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING SEWER OWoDiSPOSAL SYSTEM @ E3 00 STATE ENCROACHMENT PERMIT NO INDUSTRIAL ♦ WASTE APPROVAL OWNERS PERMIT s i 00 CHARGES AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER APPROVALS DATE INSPCCTOR S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT_ CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK SEEP PITS) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL [- DRYWELL ❑ IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAX I M THE GAL OWNER OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE A DESCR D ESI E PR ERT ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS E]OF PERMTT� SEEP PIT IS) ❑ CESSPOOLS ❑ VALIDATION ROBERT A WOOD SUPERVISING MECHANICAL ENGINEER CK M O CASH I LhL,o 3 4 6 1 UEC 14 1 1 ID 2 5.0 0 a