HomeMy Public PortalAbout4853 CLOVERLY AVE_Sewer__ r � C
62
76A642D APPLICATION FOR PER T '
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOS
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS J
WILLIAM A JENSEN Sup t of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
O OF BLD S
SIZE OF LOT NOW ON LOT FDISTRICT
TEL NO
USE OF NO GROUP MAP PROCES D BY
BUILDINGS
K PG
CONTRACTOR
ADDRESS CONNECTI N DATA
CI7Y TELNO DEPTH
SX TATE MANHOLE REFERENCE
REGISTRATION NO �' COUNTYLOWER
NO DESCRIPTION OF WORK FEE PE OF CONNECT ON LENG H FR �..
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP O�
PUBLIC SEWER @ $3 00 PC NO v
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO V
PITS AND/OR DRAINFIELD @ 51000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT O
PRIVATE DISPOSAL SYSTEM $3 00 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I AIVEE I EASEMENT RECORD INSTR N —D A
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500 yy
ALTER REPAIR OR ABANDON HOUSE HWY ORST WIDENING b
SEWER OR DISPOSAL SYSTEM @ S300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN�AME. CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS)V`DAY OF 19_
OWNER OR N NEW HOUSE SEWER (�� , �rt�iy��
OWNERS AGENTc lAl
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
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
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOV2�E DESLRIBED RESIDENT L PROPE TY ABANDON HOUSE SEWER
Ls
NATURE BACKFILLSEPTIC TANKS ❑F PERMITTEE SEEP PIT S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
�Iu,o 0 DEC18 1 0 7.0 0-