HomeMy Public PortalAbout5628 CLOVERLY AVE_Sewer__ -76A642D
663 12.54 AP LICA T'IO , 11 O ■ PERMIT _ 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE D I S P®SAL.
Department of County Engineer
County of Los Angeles ;tNE
WM. J. FOX, COUNTY ENGINEER t� r� w G°
F
CASSATT D. GRIFFIN, Sl1P'T OF BUILDING
FOR APPLICANT TO FILL IN c .
LEGAL ,
DESCRIPTION LOT N0. OWNER
z
BLOCK TRACT MAIL
MAIL
ADDRESS "
NO. OF BLDGS. j
SIZE OF LOT NOW ON LOT A CITY _ TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP
CONTRACTOR , „� W. e p _/ e BK PG
i' �0 Az
ADDRESS ...�� � ONIDTECTION DATA
CITY fes TEL. N0. ,O' 3 STATIONDEPTH /a
REGISTRATION N0. •e ❑ STATE _ ANHOLE REFERENCE
PPER
/` -3 e l� Com- �Y�o .TC7 : L^9MrE{t
E - TYPE OF CONNECTIO4 LENGTH FROM
No. DESCRIPTION OF WORK FEE Y. - 101;12, M.L.TO P.L.
R.%"- t
HOUSE SEWER CONNECTING 70
PUBLIC SEWER Q $ 3.50 cro
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. N0. / JOB. N0.
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 7.00 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 INDUSTRIAL
PITS AND/OR DRAINFIELD 2.00
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERNUT $ 1 00
AUTHORIZATION I TOTAL FEE � REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECT DATE CO
ONECTONTRTHEA ABODVEWDESCRBED EXITH THE ISTINGNAMED
DWELLIING APPROVALS DATE INSPE TOR'S SIGNATURE
TO THE PUBLIC SEWER 1 i
SIGNED THIS DAY OF _19- NEW HOUSE sewER � Wr
OWNER ORCONNECT ADDITIONAL v�
OWNERS AGENT . A� BUILDING OR WORK
ADDRESS SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL ElDRYWELL❑
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
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF D
ABANDON HOUSE SEW DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP:PITS) ❑ CESSPOOLS❑
SIGNATURE //�• //l/,�d�C.(JF/\,
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
°7 4 1� hPR 1.J � 4.5 O
.BY BY _.
DEPUTY DEPUTY
BY BY
.® DEPUTY �• DEPUTY