HomeMy Public PortalAbout5510 CLOVERLY AVE_Sewer__ 6A642D 62
7APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER EWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRES
WILLIAM A JENSEN Sup t o1 Building
LOCALITY
NEAREST
FOR APPLI T TO FILL IN CROBB ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS s
O OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUPMAP PROCES BY
BK PG '
CONTRACTO
ADDRES ,. CONNECTION DATA
CITY TEL NO �67 3dSTATIONDEPTH
Cf S STATE MANHOLE REFERENCE PPER
REGISTRATION NO �j COUNTY /
NO DESCRIPTION OF WORK PEE TYPE OF CONNECTION LENGTH F OM.:
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P
PUBLIC SEWER @ E5 00
SEPTIC TANK SEEPAGE PIT OR P C NO
@ $10 00 CO IMP NO 62
PIT$AND/ORDRAINFIELD � JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT a"
PRIVATE DISPOSAL SYSTEM @ $300 _
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EAS EN eNT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ E3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT s z o0
AUTHORIZATION TOTAL FEE t9-D CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR,S SIGNATURE
/!
SIGNED THIS DAY OF 19_ ///
OWNER OR NEW HOUSE SEWER (7 j
OWNERS AGENT_
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANKSEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE AB DESCRIBED RE ENTI PROPER Y
ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERM fTTE El
PIT(S) [:1 CESSPOOLS
VALIDATION ROBERT A WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
LAL0 6 7 3 2 NOV 8 1 0 O 7.0 0-