HomeMy Public PortalAbout5016 CLOVERLY AVE_Sewer__ �J
A642D
CEAPPLICATION FOR PERMIT
ceeoe a 59APPLICATION
OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINMM _
BUMDING AND SAFETY DIVISION BUILDING
5 0
OHN A LAMSIE, County Eag�neor
` C AIT D GRIFFIN, Supt of Buildiag LOCALITY
FOR APPLICANT TO FILL IN FOR
t
CROSS ST
LEGAL Q Ck IT6
DESCRIPTION LOT NO OWNER ) lf--f--r
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OFDISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS BK PG
CONTRACTOR Lr, /
ADDRESS s'p (� CONNECTION DATA
CITY � —TEL NO !f $ STATION DEPTH <
STATMANHOLEMANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY LOWER
NO DESCRIPTION OF WORK FEE L� _
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L
ITS AND/OR DRAINFIELD $3 00
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
ALTPIR OR ABANDON
OR DISPOSAL SYSTEM HOUSE @ $100 - STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE 1 C REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19-. NEW HOUSE SEWEROWNER OR -I N CONECT II
OWNERS AGENT BUNLDING OR
DWORKpL
ADDRESS Slo/I SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE REA 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 I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP PIT(S) El CESSPOOLS
OF PERMITTE
Or VALIDATION ROBERT A WOOD
CK b 0 CASH SUPERVISING MECHANICAL ENGINEER
0428'E31 �,Ir 6 A 300
r:
DEPARTMENT OF COUNTY ENGINYM SEWER-SEWAGE DISPOSAL.
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
_ COUNTY OF LOS ANGELES
� ILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS
FOR APPLICANT TO FILL IN I' LOCALITY �a
BUILDING 11 NEAREST
ADDRESS ` 617—�_ CROSS ST
%LOCALITY C DISTRICT NO Ready for Inspection I PERMIT NO
NEAREST CIr A,
S
,I RECE/ Y < AT��I ISSUED BY
T
OWNERea
MAIL �.i
Q
ADDRESS / V USE ZONE OCCUPANCY MLA
CITY :,.
,9 TELNO. K P
CONTRACTOR CO IMP NO
ADDRESS JOB.NO
CITY TEL NO TRUNK PERMIT NO —STATE �
REGISTRATION NO ® COUNTYI
ROAD PERMIT NOLEGAL Q7�
DESCRIPTION LOT NO S - � I STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT � �� INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT ' NO OF BLDGS
�j �( NOW ON LOT 1 CHARGES
USE DI t ' � J CONNECTION CHARGE FEE
BUILDINGS � ai i/e`+ei►e►r� et
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO �{ REIMBURSEMENT FEF,
/ PUBLIC SEWER @ f 8501 RECEIPT NO DATE BY
�— HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR EXCEPRECORDED
_ WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING ) N� I �1TE I BY
_ SEWER OR DISPOSAL SYSTEM 1 00DISCONNECT AND ABANDO
1 \
_ AND/OR DISPOSAL SYSTEMN SEWER 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION l 3 � / DEPTH
— CESSPOOLDRYWELL �./� �/J MANHOLE REFERENCE
SPECIAL CONDITIONS ONLY 200 tj
G / _ noaco LOWER
TYPE OF CONNECTION LENGTH FROMo
OWNERS PERMIT $ 1 00 CURB P L ML TO P L n?�...._
AUTHORIZATION I TOTAL FEE 4-t`150
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING I APPROVALS INSPECTOR' SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS. __—DAY OF_ _ Iq_ NEW HOUSE SEWER �� ,s
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _ _ _ _ _ _ _ _ _ _ _ _ _ _ BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE i
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY( DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN., ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED LIESIDENTIAL PROPERTY BACKFILL SEPTIC TANK$
SIGNATURE SEEP PIT(8) CESSPOOLS
OF PERMITTEE _ -1
76A642D S&E 663 4/54