HomeMy Public PortalAbout5428 CLOVERLY AVE_Sewer__ " p�X24650 INSERTS ,
7GA642 80 APPLICATION FOR PERIVII
78A842D COUNTY OF LOS ANGELES SEWER—SEWAGE ,DISPOSAL , 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A LAMBIE County Eng�aeer
WILLIAM A JENSEN Sup t of Buildmg 'LOCALITY "
NEAREST /
FOR APP CANT TO FILL IN ceoss sT Y
DESCRIPTION LEALPLOT NO a--S—v It- /5OWNER V rn. t RU
BLOCK TRAC � �• AIL
7� ADDRESS
•
NO OF BILDGS
SIZE OF LOT NOW ON LOT CITY TEL NO r
USE OFDI DISTRICT NO GROUP MAP PROCESS Y
BUILDINGS �� � BK PG
CONTRACTOR �I b
ADDRESS �i �l CONNECTION DATA
CITY S CY TEL NO �� 7 STATION DEPTH
❑ STATE MANHOLE REFERENCE. UPPER
REGISTRATION NO S� ❑ COUNTY LOWS
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF tONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR I Y CURB P L M L TO P L
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ S2 00
HOUSE SEWER CONNECTING TO P C
CO I
PRIVATE DISPOSAL SYSTEM @ $1 00 NO JOB Wq
CONNECT ADDITIONAL BLDG OR �0�. TRUNK PERMIT NO ROAD PERMIT NO O
WORK TO HOUSE SEWER @ St 00 � U V
SEWER OR DISPOSAL ABANDON
YSTEM HOUSE @ $1 00 STATE ENCROACHMENT - pq
PERMIT NO O
INDUSTRIAL (j
WASTE APPROVAL W�
CHARGES TA
OVVNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE I I C!9 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVEDESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTgR S SIGNATURE
TO THE PUBLIC SEWER A
SIGNED THIS DA OF 9_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK-
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD _
1 HEREBY ACKNOWLEDGE THAT I 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 ALTER REPAIR SEWER OR - -
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY T T 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND _
LICENSED AS XTHA
BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER `
CALIFORNIA OAM THE LEGAL OWNER THE ABOVEL:G
CRIBED REPROPERTY BACKFILL SEPTIC TANKS ❑
NATURE /�41�_- SEEP PIT(S) ❑ CESSPOOLS ❑ '
PERMITT ,fC
Or VAIMATIOP'"\ ROBERT A WOOD
CL b o CASH J SUPERVISING MECHANICAL ENGINEER ,
LAfio 5 6 5 2 1 rP , 1 8 1 c D 3. �°