HomeMy Public PortalAbout4901 CLOVERLY AVE_Sewer__ 78A842DA;;Z F R PERMIT 1
ceeoe a sa COUNTY OF LOS ANGELES
SEWER—SEWAGE-DISPOSAL
DEPARTMENT OF COUNTY ENGHiM
BUII.DING AND SAFETY DM�aSION BUILDING
ADDRESS ,v `
77
CASSAA TT D G�RWM Supt of Builddi=ag
LOCALITY—
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FOR APPLICANT TO FILL IN ceoss sr ^ C �T �'S Cl
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DESCRIPTION LOT NO Wad-' OWNER IV S L
BLOCK TRACT Lf MAIL iQ
ADDRESS U / JL
,ten 0 OF BLDGS -g � i
SIZE OF LOT / 8r OW ON LOT CITrI J2 � TEL NO
USE OFvDINGS C c G ,r D�RICT NO GROUP
BUILDI � MAP OCESSED BY
CONTRACTOR Z , ' 6� I
/ 1 BK PG
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ADDRESS qQ $ r S�skiff„�ni9a/JCONNECTION DATA
CITY ���JyC� TEL NO STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY LOWER
No I DESCRIPTION OF WORK FEE 9
HOUSE SSEWER WERCONNECTING TO @ a3 00 GPUBLI
'E OF CONNECTI N LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TOP L
PITS AND/OR DRAINFIELD @ $3 00 D
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1 00
ALTESEWER OR DIISPEPAIROSAL SYSTEM ABANDON HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMT ` S 1 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTINGA CONTRACT WITH THE HEREINAMED DWELLIING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT ((((IIII����-t BUILDING OR WORK "�1 7��C'✓ �6.d..
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 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 °
1 HEREBY CERTIFY THAT I 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 T ABOVE
DESCRIBED RESIDENTIA PROPERT tit /� BACKFILL SEPTIC TANKS El
SIGNATURE 2, A SEEP PITS) ❑ CESSPOOLS ❑
t
OF PERMITTEE
®” LIDATION ROBERT A WOOD
Cx H o CASH SUPERVISING MECHANICAL ENGINEER
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