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Home My Public Portal About5719 CLOVERLY AVE_Sewer__ 76A 6420 - CE808 - 9/73 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ADDRESS (f LOCALITY `NEARE ) FADDRESS OR APPLICANT TO FILL IN _ROSS SST T2_ L I TION L 0 T N �� OWNER �Q T Ic I ) MAIL TRACT oe ADDRESS LOT6�/('LTo 6Jc NOWOFF ON LOTS CITY T ` TEL NO USE DISTRICT NO GROUP MAP tIPROC S D BY S �sr�t� BKP3 TOR 13" /�l�L % h '�.Z/8 �^R1 �a . CONNECTION DA 6714-1 � iJ(ip�'1�'�f V TEL NO / Z STATION DEPTH STATE ' _ LIC I MA LE RE E PPEFt LICENSE NO T CLASS NO DESCRIPTION OF WORK FEE TYPE OF CON NECTI N LENGTH FROM HOUSE SEWER CONNECTING TO Y CURB PL ML TOP L PUBLIC SEWER $7 00 SEPTIC TANK SEEPAGE PIT OR JOB NO C NO PITS AND/OR DRAINFIELD @ $1000 CO IMP NO HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO PRIVATE DISPOSAL SYSTEM _ @ $300 CONNECT ADDITIONAL BLDG OR —e AFFIDAVIT wAIYI■ [AS[Y[KT RECORD INSTR NO DATE WORK TO HOUSE SEWER @ $300 U p� OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL Q $500 C.7 HWY OR ST WIDENING ALTER REPAIR OR ABANDON HOUSE C) SEWER OR DISPOSAL SYSTEM $300 (-- STATE ENCROACHMENT MANHOLE @ $7 00 PERMIT NO ♦ W INDUSTRIAL CL WASTE APPROVAL N OWNER'S PERMIT E ti p CHARGES AUTHORIZATION TOTAL FEE il� 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 SE7R APPROVALS DATE INSPECTOR S SIGNATURE SIGNED THIS DAY O 19l� OWNER OR NEW HOUSE SEWER OWNERS AGENT (((///�� ✓� ,rte CONNECT ADDITIONAL �IO ADDRESSBUILDING OR WORK 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S) AND/OR DRAINFIELD AND STATE TNAT THE ABOVE Ig CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIF CRNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AN RESIDE IN THE ABOVE RIB D RESIDENTIAL PROPERTY ABANDON HOUSE SEWED SIGNATURE ❑ OF PEftMTTTEE BACKFILL SEPTI S SEEP PIT(S) CES POOLS ❑ ALIDATION cK M D CASH 2 3 9„�}DV Z 2 1 v U 9.4 C A 6A642D 0-63 7APPLICATION FOR PERMIT 6A642 �J COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING / JOHN A LAMBIE County Eng2neer ADDRESS WILLIAM A JENSEN Sup t of Bu,ld>ng LOCALITY NEAREST FOR APPLICANT TO FILL IN C.S. ST LEGAL DESCRIPTION LOT NO OWNER f f MAIL BLOCK TRACT ADDRESS NO OF BLDGS SIZE OF LOT NOW ON LOT, z CITY TEL NO USE OF BUILDINGS DISTRICT NO GROUP MAP PR ESSED BY _ G �1 / �7 K PG CONTRACTOR I c9/1 .,{S B/- / w� J[ ADDRESS Z Un CONNECTION cD/AJTA __w CITY TEL NO �,�, Q '' 2 ?++ STATION / DEPTH 000�� PPE TATE REGISTRATION NO COUNTY MANHOLE REFERENCE / ., LOWER NO DESCRIPTION O WORK FEE TYPE OF CONNECTION LENGTH OM HOUSE SEWER CONNECTING TO ' Y UR M L T-Qd!VL d/ 9L PUBLIC SEWER @ 55 00 SEPTIC TANK SEEPAGE PIT OR PC NO O PITS AND/OR DRAINFIELD @ S1000 CO IMP NO �' JOB NO V HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO PRIVATE DISPOSAL SYSTEM $300 ^ CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE 0 WORK TO HOUSE SEWER @ $300 V OVERFLOW SEEPAGE PIT DRAINFIELD LU EXTN CESSPOOL DRYWELL MANHOLE @ E5 00 d ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING N SEWER OR DISPOSAL SYSTEM @ S3 00 STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL OWNERS PERMIT 21 00 CHARGES CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE &0 I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE TRACTOR T0C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLISEWER APPROVALS DATE INSPECTOR S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR i NEW HOUSE SEWER "1/ j ,.v� OWNERS AGENT (/ C CONNECT ADDITIONAL G BUILDING OR WORK ADDRESS SEPTIC TANK SEEP PIT(S) I HEREBY 5,C'KNCFWLEDGE THAT I HAV READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRE AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY ISTERED AND/OR ALTER REPAIR SEWER OR LICENSED AS REOUIRED LOS ES UNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT M THE GAL OW ER OF ANDTEND TO DISCONNECT PLUG AND RESIDE IN THE ABO ESCRIB D R ID NTIIPROP TY ABANDON HOUSE SEWER SIGNATURE ❑ n OF PERMITTE BACKFILL SEPTIC TANKS �p SEEP PIT(S) E3 CESSPOO S F•"Y�� ALIDATI ROBERT A WOOD v r SUPERVISING MECHANICAL ENGINEER CK M OLAC0CASH �t 6 9 7 3 NOV 1 1 0 0 7.0 O N V