HomeMy Public PortalAbout5335 CLOVERLY AVE_Sewer__ DEPA1trm7,NT OF COUNTY ENGINFER + SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER ' BUILDING
ADDRESS 5-5-3 5 U
FOR APPLICANT TO FILL IN LOCALITY T rnnlo a '
BUILDING i / AA NEAREST
ADDRESS ��^/ (��(>�Je6�Q�r/,/%(/e, CROSS ST 0/1 ua 1/J 4( /"w
LOCALITY Te�yy�e �p� DISTRICT NO SERIAL NO I PERMIT NO
NEAREST / A °3G�� 3q2 q S
CROSS ST
_ y RECEIVED lBY Ready for Inspection DATE ISSUED
OWNER53
MAIL
ADDRESS �a9�j� /(� f/�jP�� /4�ee USE ZONE OCCUPANCY MAP
BK PG
CITY2! � / TEL NO �—
CONTRACTOR
CO IMP NO
ADDRESS �iGCy
,06 No 3 P.3
CITY�r �� TEL NO
9
�4T�.Y�Oy TRUNK PERMIT NO �^
REGISTRATION NO COUNTY ROAD PERMIT NO
LEGAL
DESCRIPTION LOT NO O e S77'01C/V 2.(J-1 Cd,* STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT
a1iUroW�,a✓.�c f'�t A INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT '17,r/74/ NO OF NOW ON LOTS I CHARGES
USE OF
BUILDINGS /�{/iyj,� CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLICSEWER @ $ 350 3 RECEIPT NO I DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING NO DATE BY
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR _
PITS AND/OR DRAINFIELD 200 STATION ��(��I v DEPTH J
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2 00 / MANHOLE REFERENCE
S, v 4 UPPER LOWER
Y TYPE OFCURB
ECTIONP L " MEL T p FROM 3-11-1 /
OWNERS PERMIT $ 1 00
AUTHORIZATION TOTAL FEE CJ ,
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO TH PUBLIC SEWE APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS 7 DAY OF I NEW HOUSE SEWER
OWNER OR
S' CONNECT ADDITIONAL
OWNERS AGENF BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRES �,3—'l �?, - - - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I H VE READ THIS APPLI. CESSPOOL❑ DRYWELL E]
CATION AND STATE THAT THE ABOVE IS CORRECT AND 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 I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS
Q
SIGNATURE SEEP PIT(S)E) CESSPOOLS El
�
OF PERMITTEE _ _
76A642D 663 1/53
t
60910-63
A 642 D APPLICATION FOR PERMI
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION TNEAREST
G ^� � 0�� `�
JOHN A LAMBIE County Engineer S J '
WILLIAM A JENSEN Sup t of Building r
V C_.
FOR APPLICANT TO FILL IN ST
LEGAL
DESCRIPTION LOT NO d� lV )).,c ��Q,f OWNER
11.A" 6V �/ MAILLCve eCJBY BLOCK TRACT /�J'�J'/ � `i ADDRESS J
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY &i C� e EL NO
USE OF DISTRICT N GROUP MAP PRaCESS
BUILDINGS /�j
(O BK _- PG `
CONTRACTOR /�f/,/,✓��
ADDRESS C( 'CTION DATA
CITY � j TEL NO �� FrSTATION DEPTH
TATE UPPER
REGISTRATION NO lr(/7 OUNTY MANHOLE REFERENCE LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L >'
PUBLIC SEWER @ $5 00 CL
SEPTIC TANK SEEPAGE PIT OR P C NO O
PITS AND/OR DRAINFIELD @ E10 00 CO IMP NO JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO Q[
PRIVATE DISPOSAL SYSTEM @ 3300 0
CONNECT ADDITIONAL AFFIDAVIT WAIVER EASE.ENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER S300 O D
OVERFLOW SEEPAGE PIT DRAINFIELD W
EXTN CESSPOOL DRYWELL MANHOLE @ $500 d
ALTER REPAIR OR ABANDON HOUSE
HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
A PERMIT NO
INDUSTRIAL (7
WASTE APPROVAL J
CHAR ES
O R"S PWRMIT $ 2 00
AUTlkbRIZATIO TOTAL FEE $ G O CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR IS SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL r �•��./ ����
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S) 4' L
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS REQUIRED BY LOS ANG S COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEG OWN OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DE CRISE RESID IAL PR RTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PITS) C3 CESSPOOLS ❑
LIDATION ROBERT A WOOD
'I K M o CASH SUPERVISING MECHANICAL ENGINEER
AL'o 3 9 6 JUL 71 v D 500- 11