HomeMy Public PortalAbout5343 CLOVERLY AVE_Sewer__ 7GA6420 APPLICATION FOR PERMIT +■
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engmeer
County Of LOS Angeles BUILDING (5-
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
Ad
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
NEAREST
F +ayAP,PLI ANT F;4,IN CROSS ST
O
LEGAL � '�4 v• - ' �-
DESCRIPTION LOT NO OWNER
BLOCK TRACT
.y '� ���j ADDRESS -
SIZE OF LOT �'
rj Y /4�' NOWOONBLOTS CITY TEL NO
:1
USE OF DISTRICT NO GROUP MAP
BUILDINGS .�� BK PG
CONTRACT QA
' CONNECTION DATA
ADDRESS ~
STATION DEPTH y
CITY TEL NO
MANHOLE REFERENCE _ _ UPPER
C3 STATE 4�
REGISTRATION NO
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTIO LENGTH FROM j
PUBLIC SEWER @ $3 50 Y CURB P M L TO P L _
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO a
EXTN CESSPOOL DRYWELL,MANHOLE @ $ 2 00 CO IMP NO 1G8�M�
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 PERMIT NO '
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE _
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA ED ON APPROVALS DATE INS ECTOR S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER Qi I
SIGNED THIS rOF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK -
OWNERS AGENT zzeSEPTIC TANK,SEEP PIT(S) ,
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWL GE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNT ND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OW ER 0
F HE ABOVE
DESCRIBED RESIDENTIAL PRO RT BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS❑ _
OF PERMIT
JOHN A LAMBIE COUNTY ENGINEERVALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
eK/ M 0 .. CASH - -
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