HomeMy Public PortalAbout5022 CLOVERLY AVE_Sewer__ 4650 INSER fS
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78A842D APPLICATION_TION FO y�.q�■ PERMIT
'COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER BUILDING " 1�JIBY -
0L:
BUILDING AND SAFETY DIVISION, ADDRESS,
' - / `
IOHN A LAMBIE County En sneer
WILLIAM A JENSEN Supt of Building LOCALITY•
'NEAREST r '
FOR APPLICANT TO FILL IN u' CROSS ST
LEGAL OWNER r'DESCRIPTION LOT NOBLOCK TRACT / MAIL
ADDRESSNO OF BLDG SIZE OF LOT OW ON LOT CITY TEL NOUSE OF
BUILDINGS DISTRICT NGROUP MAP PROCESSE
BK PG
CONTRACTOR 0� / D
ADDRESS _ UU CONNECTION DATA -
CITY TEL NO STATION 3 DEPTH / �^
STATE MANHOLE REFERENCE (�j UPPER
REGISTRATION NO COUNTY - 3 Q• tfTOWER)
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO o✓f 1 7, — T "!
PUBLIC SEWER @ $3 00 V TYPE OF ECTION LENGTH FROM `
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L aZv
PITS AND/OR DRAINFIELD @ $3 00 a
OVERFLOW SEEPAGE PIT DRAINFIELD '
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER�CONNECTING TOP C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO r 6 JOB NO
CONNECT ADDITIONAL BLDG 'OR , I WORK TO HOUSE SEWER @ $100 TRUNK PERMIT NO - ROAD PERMIT NO W
- O
U
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $100 PERMIT NO O
` INDUSTRIAL
WASTE APPROVAL W
CHARGES VaI
OWNER'S PERMIT $ 2 00 ,CONNECTION CHARGE FEE
AUTHORIZATION- TOTAL FEE' 'REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR-TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATES INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWEROWNER
OWNERS AGENT "CONNECT ADDITIONAL
BUILDING OR WORK 1
ADDRES SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I�HEREBY ACKNOWLEDGE THAT 1 HAVE REA THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT ANIY AGREE TO COMPLY CESSPOOL ❑ DRY-WELL ❑
WITH ALL, COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM i r�
1 HEREBY CERTIFY TJW I AM ROP REGIST RED AND/OR
' DISCONNECT PLUG AND /
LICENSED AS REOUI Y LOS NGEL COUNTY AND STATE ABANDON HOUSE SEWER
CALIFORNIA OR T I AM TH LEG WNER E A E (( J
TANKS
DESCRIBED ID NIL PROPERT BACKSEEPFILL SEP❑CCESSP00❑LS
SIGNATURE/ ..
OF PE8 E
Lly
®" LIDATIOI� ROBERT A WOOD -
C rr 0 [CASH y SUPERVISING MECHANICAL ENGINEER