HomeMy Public PortalAbout5430 CLOVERLY AVE_Sewer__ -176AC42p, APPLICATION AOR PERMIT
B R E 663 12 54
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE D I S PIOSA L
Deportment of County Engineer
County Of LOS Angeles AD RESSG�if �
BU'L
WM J FOX, COUNTY ENGINEER
CASSATT D GRIFFIN, SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS_ S T�� ft log
C•t1t
LEGAL
DESCRIPTION LOT NO OWNER /3 (9 t^//a Ll
BLOCK TR CT1-16 - O MAIL r fl
_ADDRESS
NO OF BLDGS 7/
S12E OF LO " 210 0"'-NOW ON LOT CITY TEL NO
USE OF r"`/� -LCA
BUILDINGS // i DISTRICT NO GROUP- MAP
BK PG
CONTRACTOR
ADDRESS Z �Z �.^/ �'3 7 CONNECTION DATA
CITY �� TEL NOA7 -77 Z TATION DEPTH
s
_ ❑ STATE MANHOLER LOWERREFERENCE LOER
REGISTRATION NO / �j f/ �Y ElCOUNTY
TN OF CONNECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE Y CURB P L M L TOP L
HOUSE SEWER CONNECTING TO
'PUBLIC SEWER Q $ 3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
I CONNECT ADDITIONAL BLDG OR CO IMP NO JO NO
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
_ AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL ,
CESSPOOL- DRYW ELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECT N CHARGE FEE
OWNER'S PERMIT $ t 00
AUTHORIZATION TOTAL FEE O D REI URSEMENT FEE
01
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR S SIG
RNATUR
TACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER
NEW HOUSE SEWER
SIGNED THIS-DAY OF 19_ -
Y/Q/r CONNECT ADDITIONAL
OWNER OR
BUILDING
OWNERS AGENT_ JyWORK '2] gl
_ SEPTIC TANK, SEEP, PIT(S) -
ADDRESS - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/ORS DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM T E LEGAL OWNER F THE ABOVE
DESCRIBED RESIDENTIAL PROP TY BACKFILL SEPTIC TANKS❑
SEEP PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTEE -
WILLIAM J FOX,COUNTY IVNGINErR VALIDATrI,ON JUL /� 200
j /�
. B7 y ,.-�Co BY$ 1 JU2 Q 4 C. V C
DEPUTY DEPUTY
>BY BY ✓
® DEPUTY PUTY/
1