HomeMy Public PortalAbout5701 CLOVERLY AVE_Sewer__ E 6D89 11 39
S@ APPLICATION FOR PERMIT` 1
8 E 8
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Depar ent of County Engineer
County of Los Angeles BUILDING �� O
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST �iuey 6 A�
LEGAL $.. (2:k
OWNER
DESCRIPTION LOT NO
MAIL -
BLOCK TRACT ADDRESS
NO OF BLDGS CITY TEL NO `
SIZE OF LOT NOW ON LOT /C
USE OF DISTRICT NO GROUP MAP
BUILDINGS L �Q.
BK PG
CONTRACTOR ti
ADDRESS '�Z !• w /�?r)r'# i R 4 CONNECTION DATA
STATION DEPTH
T
CITY A 4,0 ti�c' TEL NO 6
e� MANHOLE REFERENCE � UPPER
REGISTRATION NO �a [IOC UT
G TY W
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF TION LENGTH FROM 2
PUBLIC SEWER _ @ $3 50 j�(� Y CURB P L M L TO P L J J
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1 00 C C� PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE t
OWNERS PERMIT $ 1 00
REIMBURSEMENT FEE
5
AUTHORIZATION TOTAL FEE L
APPROVALS DATE INSPECTOR SSIGNATURE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING 1
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS o DAY OF 19 CONNECT ADDITIONAL V�
OWNER OR ��oo����iiQ J BUILDING OR WORK
OWNERS AGENT[ gIS4d SEPTIC TANK,SEEP,PITS)
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
1 HEREBY CERTIFY THAT IAM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER J
CALIFORNIA OR THAT I A THE LEGAL OWNER OF THE ABOVE _
DESCRIBED RESIDENTIAL P PERTY BACKFILL SEPTIC TANKS
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS❑
OF PERMITTE
JOHN A LAMBIE C NTY tNGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
E1
CK 0 ASH
ACo 8 6 2 2 1 , MAY 2 8 4 5.5 O to