HomeMy Public PortalAbout5741 CLOVERLY AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
DDRESS S 7� r
A ' +
FOR JAPPLI ANT T FILL IN
LOCALITYBUILD
ADDRESNG S . ( NEAREST
(�`�\ CROSS ST __)/j/",o^/4,iF i -Gr.yL
LOCALITY DISTRICT NO SERIAL NO PERMIT NO
NEAREST C.51— A /LY 71 S
CROSS ST _ RECEIVED
i Ready for Inspection DATE ISSUED
OWNERMAIL e� I �� S.
ADDRESS S-/ L(I 1 USEZONE OCCUPANCY
Z> BK PO
�
CITY TEL N V
CONTRACTOR / �. �,4
CO IMP NO f
ADDRESS ,3JOB NO
CITY L NO y Q,�� i TRUNK PERMIT NO
If REGISTRATION NO �� p� ` JKCOUNTY ROAD PERMIT NO y� .7/p2
LEGAL
DESCRIPTION LOT NO JY// J" 0��L ',IJ , 9U\5 STATE ENCROACHMENT
/ PERMIT NO
BLOCK TRACT S-� 1 INDUSTRIAL
WASTE APPROVAL
- NO OF
SIZE OF LOTJ0 X 9✓ NOW ON LOTS JCHARGES
USE OF
BUI DI N G S of j CONNECTION CHARGE}`` EE
NO DESCRIPTION OF WORK EE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUB LICSEWER Q $ 350 .S RECEIPT NO I DATE BY
HOUSE SEWER CONNECTING TO t
PRIVATE DISPOSAL SYSTEM 1 00 1
CONNECT ADDITIONAL BLDG OR , EXCEPTIOr RECORDED
J WORK TO HOUSE SEWER 1 00 �( J
N DATE BY
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER + -,
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/ORDRAINFIELD 200 STATION :f_ AC`: DEPTH /n
SPECIIALCOND T ONSONLY 200 I rye/ / / MANHO�pLE REFERENCE LOWER
7S 6TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ I 1 ^` culls -III—rM L To P L
AUTHORIZATION I TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING, APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE/PUBLIC SEWER
SIGNED THIS OF 194J I NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENTIt BUILDING OR WORK
F 'a SEPTIC TANK,SEEP PIT(S)
ADDRESS IfVw AND/OR DRAINFIELD
1 HEREBY A KNOWL DGE THAT 1 THIS APPLI- CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE IS REG AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANC AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THATRE AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE
�DESCRIBE IDENTI L PROPERTY BACKFILLSEPTIC TANKS
�
SIGNATURE '" C �O SEEP PIT(S)0 CESSPOOLS �� o
OF PERMITTEE ) _
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