HomeMy Public PortalAbout5617 CLOVERLY AVE_Sewer__ CE806 12 ae
76A 642D Ar,PPLICA TION FOR PERMIT
COUNTY OF LOS.ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FCROSSI
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JOHN A LAMBIE. COUNTY ENGINEER SS
COLEMAN W JENKINS SUP T OF BUILDING
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gST F_ /
FOR APPLICANT TO FII.L IN
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LEGAL 'f,
DESCRIPTION LOT NO OWNER 7 tq 01 I L .1
MAIL _
BLOCK TRACT / ADDRESS
NO OF SLDGb _
SIZE OF LOT NOW ON LOT CITY A LE r(r TEL NO
USE OF
BUILDINGS ^�N//�/' � �s ooA4 DISTRICT NO GROUP MAP PROCESSED BY
_ BK PG
CONTRACTORe D L- Z) 1
ADDRESS 5 9 �I(,{�" pv� CONNECTION DATA
CITY A7 b TEL NO 4 Ll 2- - L1660 STATION DEPTH
STATELICENSE NO ( 4( 70/ 7— CLASS G- �LIC
UPPER
MANHOLE REFERENCE LOWER
NO I DESCRIPTION OF WORK FEE TYPEONNECTION LENGTH F5eM
OF C
HOUSE SEWER CONNECTING TO Y CURB PL M L TOVlL
PUBLIC SEWER $S 00
SEPTIC TANK SEEPAGE PIT OR PC NO
PITS AND/OR DRAINFIELD 1, flo 00 CO IMP NO .108 N
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO RO PERMIT NO
PRIVATE DISPOSAL SYSTEM $3 00 CL
C)
CONNECTIADDITIONAL BLDG OR AFFIDAVIT WMVEE EASEMENT E RD INSTR NO DATE U
WORK TO HOUSE SEWER I S300
C
OVERFLOW SEEPAGE PIT DRAINFIELD C)EXTN CE DRYWELL MANHOLE $500
REPAI R#.�A. HWY OR ST WIDENING W
M @ $300 STATE ENCROACHMEN d
PERMIT NO N
Z
INDUSTRIAL
CHARGES
WASTE APPR0 L
OWNER'S PERMIT s i o0
AUTHORIZATION TOTAL MEI 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 I APPROVALS DATE IN ECTOR S IG ATURE
SIGNED THIS DAY OF I9
OWNER OR I NEW HOUSE SEWER
OWNERS AGENT_ ` CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
AND�OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEW RS CESSPOOL ❑ DRYWELL
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED�. .E
LOS ANGLES COUNTY A STA OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I LE AL OW ER F` IN TO DISCONNECT PLUG ANDRESIDE IN THE ABO RIB�Ri51` P ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS E]OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATIJACK R ALLEN
-
CK M o GASH SUPERVISING MECHANICAL ENGINEER
6-C-9 3 JUL 2 9 1 0 D 5.0 0
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