HomeMy Public PortalAbout5605 CLOVERLY AVE_Sewer__ i
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CEBO811-87 APPLICATION FOR PERMIT
1
_ COUNTY OF.LOS ANGELES SEWER--SEWAGE, DISPOSAL "
T DEPARTMENT OF COUNTY ENGINEER
B=ING AND SAFETY DIVISION BUILDING,
JOHN A IAMBIE County En eer ADDRESS
CASSATTD GRIFFIN Supt of Bu Id-g
LOCALITY
FOR APPLICANT TO FILL IN CROSS ST r'
LEGALr ,
DESCRIPTION LOT NO F Q fIv 7- OWNER -
BLOCK TRACT ADDRESS i ' 1 -
NO 0 BLD
SIZE OF LOT N LO CITY t' TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP I MAP
CONTRACTOR BK PG
ADDRESS _ CONNECTION DATA
CITY TEL NO pie SIATION DEPTH
REGISTRATION NO Q �_� � VTATE MANHOLE REFERENCE UPPER
LJ COUNTY y LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 50
SEPTIC TANK SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
ITS AND/OR DRAINFIELD @ $3 00 Y CURB P L M L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR �,1
WORK TO HOUSE SEWER @ $1 00 E+'T/ TRUNK PERMIT NO ROAD PERMIT NO
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
- WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 1 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE - Od REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT 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 - - - - - --- CONNECT ADDITIONAL - - -'-'
OWNERSAGENTyY' BUILDING OR WORK
ADDRESS - - - - - - SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 1 -
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 THAT I AM PROPERLY-REG ISTRED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUI •D BY LOS APGELES C UNTY D STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR T TFJk' L GAL NER -THE ABOVE - - -SIGNATDESCRURE
RES, 1 � SEEPFPIT(S)ILL PTIC TANKS
❑CESSPOOLS ❑
SIGNATURE _
OF PERMITTE
01, - - VALIDATIO ROBERT A WOOD'
CK R O_ CASH _ - SUPERVISING MECHANICAL ENGINEER
--- - -_ - LACo4 3 1 1U_, AUG 2 8-10 A _ 2.0 0 M