HomeMy Public PortalAbout5031 CLOVERLY AVE_Sewer__ a
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E APPLICATION FOR PERMIT
88DMSION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County Of LOS Angeles JLADDRESS
ILDING
JOHN A LAMBIE COUNTY ENGINEER OCASSATTD GRIFFIN SUPTOFBUILDINGLITY rs
FOR APPLICANT TO FILL IN CROSS s
LEGAL4 /6 OWNER
/
DESCRIPTION LOT NO "f
BLOCK TRACT ADDRESS O
NO CO' BLDGS CITY 16� TEL �j V '
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO GROUP MAP
BUILDINGS '
BK PG
CONTRACTOR 10_3
ADDRESS 6, J` �} h _� . CONNECTION DATA
CITY T L NO STATION O ��/ DEPTH
MANHOLE REFERENCE UPPER
///1 Ll� ❑ STATE LOWER
REGISTRATION NO �l ! 11COUNTY
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH ROM
Y CURB PL M L TOPL
PUBLIC SEWER @ $3 50
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL,MANHOLE Q $ 2 00 CO IMP NO 10B NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1 00 a PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APP 0 AL
` GES
CON ECTION CHARGE FEEtj✓�i� _
OWNERS PERMIT S 11 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF I9 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK `
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL F-1DRYWELL ElAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I 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 PROPERTYBACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) LJ CESSPOOLS❑
OF PERMITTEE
JOHN A LAMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK b 0 CASH
_XO2088N MAR 18 4 A 3.00