HomeMy Public PortalAbout4908 CLOVERLY AVE_Sewer__ 7GA642D /
S&E 663 11 55 APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engmeer
County of Los Angeles BUILDING _
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
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® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS s
LEGAL
DESCRIPTION LOT NO iq. 10
OWNER MAIL
BLOCK TRACT l /' �-Al ADDRESS
NO OF BLDG CITY TEL NO
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO GROUP MAP
BK PG
BUILDINGS _
CONTRACTOR ` / e rO L A W
ADDRESS Z -w a �� CONNECTION DATA
CITY (� O TEL NO STATION (p 4, DEPTH
MANHOLE REFERENCE r ) UPPE
R
REGISTRATION NO / Z ( ❑ COUNTY Gam! ,'8 ,
NO DESCRIPTION OF WORK FEE l�l� /Xb
HOUSE SEWER CONNECTING TO Y YPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3 50 CURB P L M L TO P L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00 / �/�
OB N0
OVERFLOW SEEPAGE PIT DRAINFIELD J0
JOB CESSPOOL DRYWELL,MANHOLE Q $ 2 00 CO IMP NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE719 eL
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE Ll
5ra
REIMBURSEMENT FEE z
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS i DATE INSPECTORSSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ,
TO THE PUBLIC SEWER I NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR ! BUILDING OR WORK
OWNERS AGENTAJNN
SEPTIC TANK SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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 M THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL OPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS❑ _
OF PERMITTE
JOHN A LAMBIE CO NTY ENGINEER ROBERTA WOOD CHIEF PLBG INSPECTOR
M O CASH
A';�1 3rLIDATION
ru'R 12 4 4.5 0 i