HomeMy Public PortalAbout5419 CLOVERLY AVE_Sewer__ i
76A6420 ,
S E 66911.&8 APPLICATION FOR PERMIT 1
VIVISIOI� OF BUILDING.; AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANTO L
TIN
NEAREST
LLEGAL OWNER
DERIP I N OT NO
IV MAIL -
BLOCK TRACT y ADDRESS
NO OF B DGS CITY TEL NO
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS DISTRICT NO GROUP MAP
BK
CONTRACTOR ' i X17
/
ADDRESS LCONNECTION DATA
CITY TEL NO d STAT10 J�LTi` DEPTH
- 7 T
MANHOLE REFERENCE UPPER
E-'g1'ATE LOWER
REGISTRATION NO /16k'5_l' ❑ COUNTY
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PIRS—
UBLIC SEWER Q $.."Q Y CURB P L M L TOP L
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/ JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR ISTATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S _ PERMT $ 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 U 195 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK _
OWNERS AGENT SEPTIC TANK SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ IS 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 TH I AOLE
RLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED LOS COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM TOWNER OF THE ABOVE
DESCRIBED RESI NTI PROPERBACKFILL SEPTIC TANKS❑
SIGNATURE SEEP T(S) ElCESSPOOLS❑
OF PERMITTEE AI
/
JOHN A BIE, COUNT ENGINEER ALIDATION ROBERT A WOOD CHIEF PL13G INSPECTOR
CK V 0 CASH
L, 1 78 AUG 26 1 0 A 5.00
r
76A6E42D APPLICATION FOR PERMIT 1
8& 683..IIVIND SION OF BUILDING ASAFETY SEWER-SEWAGE DISPOSAL
�/��j.: V ^Depaztment of County Engineer
County of Los Angeles BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGA -7
( OWNER i
DESCRI LO O
MAIL
BLOCK TRACT ADDRESS
2h1
4
NO OF BLBL G5 CITY TEL NO
SIZE OF LOT NOW ON LOT
USE OF i DISTRICT NO GROUP MAP
BUILDINGS
KPG
CONTRACTOR �"�'q C
CONNECTION DATA
ADDRESS —S�fVgt�n��;f ` /F
CITY TEL NO �d, ,(���_v DEPTH / 1%
�' 7 0 ^ M NH LE REFERENCE UPPER
STATE LOWER
REGISTRATION NO 16 6 ` ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3 50 Y CURB P L M L TO P L r�
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00 ,
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00 CO IMP NO (�-- 0. JOB NO
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 @ $100 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL ,
SEWER OR DISPOSAL SYSTEM @ $100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE -
OWNER'S PERMIT $ Oo
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 19 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 WIS 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 THA I AM 0 RLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED LOS A GEL COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM THE EGA OWNER OF THE ABOVE
DESCRIBED RES IDENTIA ROPERT BACKFILL SEPTIC TANKS❑
SEEP PIT(s) ❑ CESSPOOLS ,
SIGNATURE
OF PERMITTEEPA
JOHN A L BIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK E! O CASH to
i.AC01 7 8 09; AUG 26 1 1 A 2 5.0 0