HomeMy Public PortalAbout4848 CLOVERLY AVE_Sewer__ c
-61
76A6423-61
APPLICATION FOR PERMIT
76A 642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE County En eer ADDRESS
-MM
WILLIAM A JENSEN Supt of Building_ LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS sT
LEGAL
DESCRIPTION LOT NO OWNER /
BLOCK TRACT MAIL
ADDRESS
0 BLDGS
SIZE OF LOT D NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP P CESSED BY
CONTRACTOR K PG 777iii OV
ADDRESS O CONNECTION DATA
CITYTEL NO q STATION DEPTH
STATE MANHOLE REF E ENC UPPER
REGISTRATION NO (12- COUNTY LOWER
No DESCRIPTIO F FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00
SEPTIC TANK SEEPAGE PIT OR TYPE 0 CO NE TI N LENGTH FROM
PITS AND/OR DRAINFIELD @ 39 00 Y B P M L TO P
OVERFLOW SEEPAGE PIT DRAINFIELD / J >-
EXTN CESSPOOL DRYWELL @ S2 00 d
HOUSE SEWER CONNECTING TO P C NO O
PRIVATE DISPOSAL SYSTEM @ Moo CO CWINV JOB NO V
CONNECT ADDITIONAL BLDG OR TRMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER E1 00 O RUN
ALTER REPAIR OR ABANDON HOUSE STATE ENCROA NT O
SEWER OR DISPOSAL SYSTE @ $100 PERMIT NO V
INDUSTRIAL uJ
d
WASTE APPROVAL �A
CHARGE Z j
OWNERS PERMIT S 2 QQ CONNECTION ARGE FEE
AUTHORIZATION TOTAL FEF a REIMBU ENT Fff— �
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19— NEW HOUSE SEWER l
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK J I
ADDRESS SEPTIC TANK SEEP PITS) v
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
PLUMBING AND SEWERS ALTER REPAIR SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROP TY BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS
OF PERMITTE r
m0
VALIDATION----') ROBERT �4 WOOD
CLr 0 r•cB SUPERVISING MECHANICAL ENGINEER
UP 6 8 4 3 - JhH 4_0 0 `�