HomeMy Public PortalAbout5758 CLOVERLY AVE_Sewer__ D
76A642APPLICATION FOR PERMIT
6A64
COUNTY OF LOS'ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING {--
JOHN A. LAMBIE, County Engineer ADDRESS o��
WILLIAM A. JENSEN, Supt of Building ,t^
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS BT.
LEGAL
DESCRIPTION LOT NO. G OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO_—,�,
USE OF / DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS .�
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY NO. DEPTH
STATION R �I TEL. � 7 q
STATE MANHOLE REFERENCE a7 UPPE
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE TYPE OF SCT N LENGTH FROM
HOUSE SEWER CONNECTING TO �. Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD @ $10.00
CO.IMP. NO. _ JOB NO. 0
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.GR•% V
PRIVATE DISPOSAL SYSTEM @ $3.00 z
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE
WORK TO HOUSE SEWER @ $3.00 O
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 HWY. OR ST.WIDENING VVV
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT yNy
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT S 2 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR' S NATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(6)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THEVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
-10
SI OF Ap ERMITTEE BACKFILL SEPTIC TANKS ElTUGNREI
SEEP.PIT(S) ❑ CESSPOOLS' / L
ALIDATION ROBERT A. OOD
M.O. CASH SUPERVISING MECHANICAL ENGINEER
CK.
Lc 5 0 a u ?rJ 7.00-