HomeMy Public PortalAbout5338 CLOVERLY AVE_Sewer__ r �
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76A6420 • •PPLICATIONFOR PERMU
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
? BUILDING AND SAFETY DIVISION BUILDING
ADDRESS � 1'
JOHN A LAMBIE, County En moor C.-
WILLIAM A JENSEN Sup t of Building LOCALITY -
NEAREST �I K
FOR APPLICANT TO FILL IN tcROSs sT
LEGAL /
DESCRIPTION LOT NO S OWNER `
BLOCK TRACT O� MAIL '
ADDRESS
E
NO OF BLDGS Ir
SIZE OF LOT 1� NOW ON LOT a CITY TEL NO _
3
USE OF
BUILDINGS DISTRICT NO GROUP MAP I PROLE ED BY
BK PG
CONTRACTO `
ADORES V CONNECTION DATA - "�
CITY �/7 TEL NO STATION DEPTH
(% / 7✓ STATE MANHOLE EFERENCE ER
REGISTRATION NO COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO `
P t PUBLIC SEWER @ $3 00 (J TYPE OF CONNECTION LENGTH FROM D /
SEPTIC TANK SEEPAGE PIT OR CURB P L M L TO P L
^ PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGEPIT DRAINFIELD '
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P10C-Ci•0•' 3 O
PRIVATE DISPOSAL SYSTEM @ $1 00 },
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO O
WORK TO HOUSE SEWER @ $1 00 U
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT P4
SEWER OR DISPOSAL SYSTEM @ $1 00 PERMIT NO
e b INDUSTRIAL ^
WASTE APPROVAL } W
CHARG
OWNER'S PERMIT $ 2 00 '' CONNECTION CHARGE
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 DATE INSPECTORS SI NATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
CONNECT ADDITIONAL '
OWNERS AGEBUILDING OR WORK ^ '
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY, ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PETER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
t I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND _
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER `
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER 0 THE ABOVE +
DESCRIBED RESIDE IAL PROP hTY BACKFILL SEPTIC TANKS Cl
SEEP PIT(S) ❑ CESSPOOLS ❑. -
SIGNATURE
OF PERMITTE
®r LIDATION ROBERT A WOOD
CIL 41 M 0 _ CASH SUPERVISING MECHANICAL ENGINEER
I,)ten 1 9 9 _ w (�` 5 C' fi
5 'D J,