HomeMy Public PortalAbout5616 CLOVERLY AVE_Sewer__ APPLICATION
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engmeer
County of Los Angeles BUILDING of-
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WM J FOX, COUNTY ENGINEER ADDRESS (o -
CASSATT D GRIFFIN SUP T of BUILDING 4LOCALITY
FO APPLIC T TO FILL IN NEAREST
CROSS ST ~
LEGAL 0• • L- _
DESCRIPTION LOT NO OWNER
BLOCK TRACT ADDRESS
NO OF BLDGS 11
SIZE OF LOT NOW ON LOT .2 CITY �� a TEL NO
USE OF
BUILDINGS L +DISTRICT NO GROUP MAP PG
CONTRACTOR i " eo, I T I m BK„ /3O
ADDRESS of CJ CONNEECTION DATA l,7W�.{
CITY � d// TEL NO .O� &712 STATION /6 _k L�� DEPTH
��/�_ �^ �� ❑ STATE MANHOLE REFERENCE
REGISTRATION NO i Y Ir WER
UPPER L
OL
TYPE OF CONNECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE Y CURB P L M L TOP L
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q Y 3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR CO IMP NO �/ JOB NO
WORK TO HOUSE SEWER 1 00 Z, ryryry
ALTER OR REPAIR EXISTING ���/
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO Q
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 $ 1 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECTDATE ONTRTHEA ABOVECTED WDESCR BEDITH THE H EXISTING NAMED
DWELLING CON APPROVALS DATE INS ECTOR SSIGNATURE
TO THE PUBLIC SEWER
NEW HOUSE SEWER
SIGNED THIS DAY _19_
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
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/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SEEP PIT(S) ❑ CESSPOOLS❑
SIGNATUPE
OF PER141 TEE
WILLIAM J FOX, COUNTY ENGINEER VALIDATION
BY y�f,02 7Y4 3 n APR 19 4 4.5 0 a
DEPUTY DEPUTY
BY BY
0 DEPUTY DEPUTY