HomeMy Public PortalAbout4902 CLOVERLY AVE_Sewer__ C E808 10-63 Y
76A642D APPLICATION OR 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 Building
LOCAL TY
NEAREST
FOR APPLICANT TO FML IN CR05S 5T
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLD(;S
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO I GROUP MAP ESSED BY
♦r BK ` PG
CONTRACTOR /_
ADDRESS , CONNECTION DATA
CITY
STATION DEPTH
EL NO
TE MANHOLE REFERENCE /
REGISTRATION NO COUNTY ` LOWER
NO DESCRIP F WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ $5 00 d.
SEPTIC TANK SEEPAGE PIT OR P C NO JOB NO O
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO -11114 V
HOUSE SEWER CONNECTING TO TRU P ROAD PERMIT NO o[
PRIVATE DISPOSAL SYSTEM @ $3 00 0
CONNECT ADDITIONAL BLDG OR A (DAVIT wMv w [As[MENT E ORD INSTR NO DATE
WORK TO HOUSE SEWER $3 00 V
OVERFLOW SEEPAGE PIT DRAINFIELD W
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 21 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATIONTOTAL 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
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK r
I HFREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S) (�
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 ❑
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 THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED ESIDE NTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE ' BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A wooer
CK M O CASH SUPERVISING MECHANICAL ENGINEER
La110NOV 6100 5.0 0 r