HomeMy Public PortalAbout5743 - 5745 - 1/2 CLOVERLY AVE_Sewer__ &E 6D89 11 55 i V 1
SAPPLICATION FOR PERMIT
8&E 6 ,
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department`of County Engmeer
COIIIIty Of L08 Angeles BU AD
.RES'
p z"tqV� �"
JOHN A LAMBIE COUNTY ENGINEER
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY =/j/f
zj/
imammosw CRSSSOR APPLICANT TOFI IS OT 1AI 12 2r om'wz
LEGAL � OWNER LOTNO V
,67-D/ r
BLOCK - TRACT �s /� ` ADDRESS 7 3 C'4 D !YV 9D
NO OF BLDGS
SIZE OF LOT " ON LOTUSOF
CITY t e / TEL NO
BUILDINGS DISTRICS-N49^ GROUP MAP
BK PG
CONTRACTOR �--� L 13
ADDRESS 6� CONNECTION DATA
STATION DEPTH
CITY �41- TEL NO
MANHOLE REFERENCE
,/ ❑ STATE 0& LOWE
REGISTRATION NO G' ❑ COUNTY
NO DESCRIPTION F WORK FEE y,
�1 TH FR(
HOUSE SEWER CONNECTING TO TYPE 0 CURB�TIO MEL GTO P L M /
/ PUBLIC SEWER @ $3 50
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00 CO IMP NO /3 / JOB NO
�T
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT N
CONNECT ADDITIONAL BLDG ORSTATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 D PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL
c
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 Do
AUTHORREIMBURSEMENT FEEIZATION TOTAL FEE '
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS` DATE IN ECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER 1t
SIGNED THI DAY OF 19 CONNECT ADDITIONAL
OWNER OR —� BUILDING OR WORK II -F
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS 47f2 AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE D THIS APPLICATION CESSPOOL❑ DRYWELL❑ '
AND STATE THAT THE ABOVE IS CORRECT ND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUS S
CALIFORNIA OR THAT AM H L GA 0 OF TH ABOVE
DESCRIBED RESIDENTI ROP
'b7+'v"" BACKFIL S,01
SIGNATURE SEEP PIT OOLS[:3
OF PERMITTEE
s
JOHN A LAMBIE.,COUNTY ENGINEER VALIDATI ROBERT A WOOD CHIEF PLBG INSPECTOR
ti
CK m O CAS
0099 SPR 9 4 550 �'