HomeMy Public PortalAbout4930 CLOVERLY AVE_Sewer__ 89E 6639 53 APPLICATION FOR PERMIT
DIVI910N OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL.
Deportment of County Engineers
County Of LOB Angeles ADDRESSG ����
WM J FOX, COUNTY ENGINEER
CASSATT D GRIFFIN, SUP T OF BUILDING LOCALITY I���� � �'/1✓YT Y
FOR APPLICANT TO FILL IN CROSS ST i
LEGALn .
DESCRIPTION LOT NO /7 OWNER A�.11'gyp
BLOCK TRACT MAIL Q d q
ADDRESS --ar
NO OF BLDG$
SIZE OF LOT 'NOW ON LOT CITY TEL NO
USE OF
BUILDINGS /.G. ( DISTRICT NO GROUP MAP
BK I PG
CONTRACTOR � Z: �1..� a
ADDRESS CONNECTION DATA
CITY r a TEL N � �� STATION . DEPTH 0
f [I STATE MANHOLE REFERENCE
REGISTRATION NO 1100weP 171F' ❑ COUNTY LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE NECTION LENGTH FROM
PUBLIC SEWER ® $ 3 50 Y CURB P L M L ,O P L �q0 ^
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG ORP C NO
WORK TO HOUSE SEWER 1 00 CO IMP NO JB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANY SEEPAGE PIT OR INDUSTRIAL
PITS AND/OR DRAINFIELD 00
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
OWNER'S PERMIT S t 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE ( .5z REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECT THE DATE ABODVEWDESCR BED EXIISTINGITH THE HEREIN A DWELLING CON APPROVALS ATE INSPEC AOR S SIGNATURE o
TO ThE PUBLIC SEWER
SIGNED THIS DAY OF I9 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL C3 DRYWELL C)AND STATE THAT THE ABOVE IS CORRECT AND AGPEE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOIE ABANDON HOUSE SEWER
DESCRIBED RESIDENT L PROISERTY
BACKFILL SEPTIC TANKS❑ {�
SEEP PIT(S) [3l� S�4 CESSPOOLS IO U.....nu
..�
SIGNATURE
OF PERMITTE
WILLIAM J FOX,COUNTY ENGINECR VALIDATION R A WOOD. CHIEF PLBG INSPECTOR
LACO 0 4 3 4 SEP 21 4 4.5 0 In