HomeMy Public PortalAbout4942 CLOVERLY AVE_Sewer__ TEKPLE CITY
6A642D 62
7APPLICATION FOR PERMIT
6A842
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS4942 N. Over1
COLEMAN W JENKINS SUP T OF BUILDING
LOCALITY TeMple City
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T
LEGAL C
DESCRIPTION LOT NO 16 OWNER
MAIL
BLOCK TRACT 3�� ADDRESS4128 N. Cedar Ame
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS Res.
_ BK PG
CONTRACTORSquare Deal Sewer Service S� & l0
ADDRESS 2933 MaxannCONNECTION DATA
CITY Monte TEL NO STATION DEPTH
STATE LIC U
MANHOLE REFERENCE
LICENSE NO CLASS OWER
NO DESCRIPTION OF WORK FEE TYPE OF C ON LENGTH FROM
HOUSE SEWER CONNECTING TO oo Y CURB P L M L TO P L d
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR P G NO O
PITS AND/OR DRAINFIELD @ STOOD CO IMP NO JOB NO u
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO w
PRIVATE DISPOSAL SYSTEM @ S3 00 zz O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300 u
OVERFLOW SEEPAGE PIT DRAINFIELD Lu
EXTN CESSPOOL DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING H
SEWER OR DISPOSAL SYSTEM @ S3 00 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s z o0
AUTHORIZATION TOTAL FEE 7
CONNECTION CHARGE FEE
IHAVE 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 INeCTOR
S NATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER `1
OWNERS AGENT_ CONNECTADDITIONAL
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 ❑
I HEREBY 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 IAM THE LEGAL OWNER F AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESIDENTI PR ERTY ABANDON HOUSE SEWER
7
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS
VALIDATION JAEFWALCEN
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
Ljeo4 6 & 5my 13 1 0 D 7.00-