HomeMy Public PortalAbout5516 CLOVERLY AVE_Sewer__ S&6 63 3 se APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL.
Deportment of County Engmeer
County of Los Angeles J7A_DEWM J FOX, COUNTY ENGINEERCASSATT D GRIFFIN, SUPT OF BUILDINGF�
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FOR PLICANT TO FILL IN CROSS ST
LEGAL ,
DESCRIPTION L T NO (S7 2 OWNER
BLOCK TRACT ,`�� pAIL
DRESSNO
Q
SIZE OF LOT d NOWOONBLOTS CITY TEL NO
/Y 3 d �
USE OF
BUILDINGS DISTRICT NO GROUP MAP
BK PG
CONTRAC70R �, � so
ADDREpS/�5,, CONNEECTION DATA
CITY �!/ TEL NO J0 Id, �,�� STATION f '��%1 J DEPTH / �"
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MANHOLE REFERENC'c�C � UPPER
REGISTRATION NO 91 9 3 6 ❑ COUNTY �7
NO DESCRIPTION OF WORK FEE
TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO r Y CURB P L M L TO P L
PUBLIC SEWER Q $ 3 50 J
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00 _
CONNECT ADDITIONAL BLDG OR �/ J P C NO
WORK TO HOUSE SEWER 1 00 CO IMP NO Ip c'o JOB NO
ALTER OR REPAIR EXISTING 33 7 30
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- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT S 1 00
AUTHORIZATION I TOTAL FEE I_50 REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS -DAY OF 19- NEW HOUSE SEWER
OWNER OR {i s� CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK, SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
IO ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL C3 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/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AI4D STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PR ERTY BACKFILL SEPTIC TANKS❑
SEEP PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTEE
WILLIAM J FOX,COUNTY ENGINEER VALIDATION R A WOOD. CHIEF PLBG INSPECTOR
LACO 4705L APR 3 4 4-.50 �'