HomeMy Public PortalAbout5021 CLOVERLY AVE_Sewer__ IIDEPAWrMF,NT OF COUNTY ENGINEER SEWER--SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
P COUNTY OF LOS ANGELES
WILLIAM J FOX, COUNTY ENGINEER BUILDING D2
� ADDRESS
FlO!R APPLICANT TO FILL IN LOCALITYBUI
NEAREST
ADDRELD'SS CROSSST (� S
LOCALITY DISTRICT NO SERIAL NO PERMIT NO
NEAREST ^� A 'll �4+��f�
CROSS ST _ ��j✓
,� RE EIVE B Ready for Inspection DATEISSWED
OWNER '� �� ,71,5—
MAIL
ADDRESS 0 Z- rr —t USE ZO OCCUPANCY AP
BK PG
CITY TEL NO J o 4 D
CONTRACTOR
CO IMP NO
ADDRESS S l ' JOB NO
3 CITY TEL N -0 j 6
TRUNK PERMIT NO
REGISTRATION NOf�� COUNTY 7
ROAD PERMIT NO
LEGAL /
DESCRIPTION LOT NO / STATE ENCROACHMENT
$ PERMIT NO
BLOCK TRACT 'J3 2-9 INDUSTRIAL
WASTE APPROVAL
SIZE OF LOTS/3 X J NOW ON LOTNO BF S CHARG
USE OF / y
BUILDINGS CONNECTION CHARGE FE
NO DESCRIPTION OF W RK FEE
HOUSE SEWER CONNECTING TS
REIMBURSEMENT FEE
PUBLICSEWER a $ 350 RECEIPT NO I DATE IBY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR E CEPTIO RECORDED
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING NO I TE BY
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR 7 ,
PITS AND/OR DRAINFIELD 200 STATION f �Jo DEPTH
CESSPOOL—ORYWELL
SPECIALCONDITIONS ONLY 200 / NHS�OLEREFERENCE LOWER
TYPE OFECTION LENGTH FROMI
OWNERS PERMIT $ 1 00 �"-"�' s� m L TO P L
AUTHORIZATION I TOTAL FEE 7 30
1HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGAPPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS DAY OF _ _194_y NEW HOUSE SEWER
_ � r
OWNER OR \ CONNECT ADDITIONAL
OWNERS AGENT L �ka 7C ) " '—lr _ _ BUILDING OR WORK
ADDRESS L a L �J ��\_ t+ "�S SEPTIC TANK,SEEP PIT(S)
�` AND/OR DRAINFIELD
I
HER ACKNOWLEDGE THAT I HAVE READ r�{IS APPLI- CESSPOOL E] DRYWELL 0
CATION AND STATE THAT THE ABOVE IS CORRECT D AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I 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 I AM THE LEGAL OWN- ABANDON HOUSE SEWER i
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS ' a
SIGNATURE/G-' TG SEEP PIT(S)Ej CESSPOOLS
OF PERMITTEE
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