HomeMy Public PortalAbout5622 CLOVERLY AVE_Sewer__ 5& D
S$E 66312 54
APPLICATION FOR PERMIT 1
6
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
} County of Los Angeles BUILDING d^/ �, ,/� •� � '
WM J FOX, COUNTY ENGINEER ADDRESS J {rte
SL
CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST
LEGAL OT • s' - 9 �
DESCRIPTION LOT NO OWNER �.y7,/�/�
BLOCK TRACT � .. -Oi.� p I+ ADDRESS
NO OF BLDGS ,A
SIZE OF LOT NOW ON LOT I CITY c i TEL NO
mmxmm
USE OF
BUILDINGS DISTRICT NO GROUP MAP PG
CONTRALTO
�- I o
ADDRESS — / ` CONNECTION DATA
CITY TEL NO 2 STATION DEPTH U
REGISTRATION NO
❑ STATE d MANHOLE REFERENCE
_ [T� �i� UPPER i,Q4FEP
�/ - TYPE OF NECTION LENGTH FROM ,✓ a
NO DESCRIPTION OF WORK FEE Y CON �+@sL M L TO P L J
HOUSE SEWER CONNECTING TO
A PUBLIC SEWER Q $ 3 50 J ✓ �-+
HOUSE SEWER CONNECTING f0
_ PRIVATE DISPOSAL SYSTEM 1 00
,CONNECT ADDITIONAL BLDG OR CO IMP NO JOB NO
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING
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
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE 14 REIMBURSEMENT FEE
TRACTORHAVE TOS CON ECTDATE O NTRTHEA ABODVEWDESCR BED EXISTINGA MED DWELLccc.oING •
APPROVALS DATE INSP CTOR S SIGNATURE
TO THE PUBLIC SEWER `
SIGNED THIS DAY OF 19- NEW HOUSE SEWEROWNER 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 j
CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE
WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEPEBY CERTIFY THAT 1 AM PROPERLY REGISTEDISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SEEP PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTEE
WILLIAM J FOX, COUNTY ENGINEER VALIDATION
,
BY 2 .74512' APR 19 4 4.50
UH
DEPUTY DEPUTY
' BY BY
® DEPUTY ����/ � DEPUTY