HomeMy Public PortalAbout5702 CLOVERLY AVE_Sewer__ ,76A6420
E 6D
8 83 12 94
APPLICATION FOR PERMIT 1
Q E 8
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of CountyEngineer
County of Los Angeles BUILDING
WM J FOX, COUNTY ENGINEER ADDRESS
CASSATT D GRIFFIN,SUP T OF BUILDING LOCALI
FOR APPLICANT TO FILL IN NEAREST /
/ ��� CROSS ST
LEGDESCRAIPTION LOT NO Tb 60! �',/d'I al OWNER
BLOCK TRACT / MAIL
ADDRES
NO OF BLDGS
SIZE OF LOT Q NOW ON LOT CITY TEL NO
USE OF y
BUILDINGS 7" DISTRICT NO GROUP MAP '
BK " PG
CONTRACTOR 1..9 X
ADDRESS m� CONNECTION DATA
CITY L NO l STATION / '� � DEPTH
STATE ® MANHOLE REFERENCE
REGISTRATION NO Q ❑ COUNTY 10�� �+''�' UPPER ^LMIVER
TYPE OF CONNECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE CURB E�t�' M L TO P L
HOUSE SEWER CONNECTING TO ri )
PUBLIC SEWER Q $ 3 50 �J(./
HOUSE SEWER CONNECTING TO
_ 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 PER NO tj 6i� vlz
DISCONNECT AND ABANDON SEWER STATE E14CROACHMENT
_ AND/OR DIS°OSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
ITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT g 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
TRACTORHAVE T TO CONNECT THEHIS DATE A ABOVECTED WDESCT BEDITH HE HEREIN FX STIN GAMED DWELLING APPROVALS DATE INSP/ CTOR S SIGNATURE
THE PUBLIC SEWER/
SISIGNED THIS ��' AY OF .. � ) NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGEN .r6 BUILDING OR(YORK
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
IHEREBY CERTIFY THAT I AM PROPERLY REGISTEPED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES TY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGA R OF T ABOVE
DESCRIBED RESIDENTI PERTY CKFILL SEPTIC TANKS❑ ,(
SEEP PIT(S) ❑ CESSPOOLS q tS 5 +-1 eA_
SIGNATURE
OF PERMITTEE
Una
WILLIAM J FOX,COUNTY ENGINEER VALIDATION
'C09987 ;� "10"15 450
BY - BY
DEPUTY DEPUTY
BY BY r
® DEPUTY V d' EPUTY