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Home My Public Portal About5803 CLOVERLY AVE_Sewer__ CE806 5-65 APPLICATIO FOR PER IT 76A64E808 D COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING 6 �� I E AL)q JOHN A LANBIL County Engineer ADDRESS COLLNIAN W JFNF.INS Sup't of Building LOCAL TY NEAREST FOR APPLICANT TO FILL IN S. (� CRDSS ST ' ` fG LEGAL �TT LO 1 % f�.� S` DESCRIPTION LOT NOSo OWNER+RA MAIL BLOCK TRACT ADDRESS SL41 6 jam, 3 rA SIZE OF LOT lW 1 4o NOWOON LOTS pt. fMANH STEL NO OL•� USE OF �� NO GROUP / MAP PROCESSED BY BUILDINGS // f BK PG p� / ) CONTRACTOR !� 1 1 K�J PI��s�� ,✓ //-\r ADDRESS f.,,,I L,(-L, ,T (� CONNECTION DATA CITY TEL NO _ j DEPTH N OCE NSE CLASSLICENMANHOLE REFERENCE rt UPPER NO DESCRIPTION OF WORK FEE OF CO 6.STION LENGTH FROM HOUSE SEWER CONNECTING TO URB ' P L ML TOPIL PUBLIC SEWER @ $ 5 00 }. SEPTI ANK S_EPAGE PIT R JO NO d. PITS AND/OR DRAINFIELD C $1 0 00 CO IMP NO 1311 JOB NO O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V f PRIVATE DISPOSAL SYSTEM C $ 3 00 CONNECT ADDITIONAL BLDG OR AFFIDAVIT wkiv ER EASEMENT RECORD INSTR NO DATE O WORN TO HOUSE SEWER C $ 3 00 0 REPAIROR N N �J SEWER OR DISPOSAL, M C-' $ 3 00 `1� W IT DRAINFILLU HWY ORST WIDENING d EXTN CESSPOOL MANHOLE LE Ci $ 5 00 STATE ENCROACHMENT Z I PERCOLATION TEST @ $ 5 00 PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT $ z 00 AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE TRACTOR TO CONNECT THE BOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SE E APPROVALS DATE INSPECTORS SIGNATURE SIGNED THIS DAY OF 79J�( OWNER OR t NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK SEEP PIT(S) I HEREBY ACKNOWLEDGE THA 1 H E READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ IHEREBY 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 THE ABOVE DESC BED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER SIGNATURE OF PERMITTE BACKFILL SEPTIC TANKS ❑ / SEEP PIT(S) ElCESSPOO VALIDATION CK M 0 CASH L110 C) 2-3 8,1; AUU22 1 D 5.00- v 04"`7� �2 C�� -7 76A642D 65 r APPLICATION FOR PERMI �j'�/�&-,-f" COUNTY OF LOS ANGELES SEW SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION 7NEAREST F JOHN A LANIBIE County Lngmeer /V) COLEMAN IN 11,NLINS Sup't of Building �� y� r /-/ ��' "'/FOR APPLICANT TO FILL IN V-r" DESLE AL CRIPTION LOT NO V L OWNER G. L .-. BLOCK TRACT � f--x / MAIL ADDRESS NO OF BL GS SIZE OF LOT NOW ON LOT CITY TEL NO USE OF BUILDINGS t n ( DISTRICT NO ROUP MAP PROCESSED BY tEIK PG CONTRACTOR eAlMEss [ ' -—(J CONNECTION DATA STATION _ -� DEPTH CI TEL NO 197C7 0 ,) LICENSE /y UPPER NO E CLASS MANHOLE REFERENCE [.��/J ,,�j f LOWER f 5r NO bESCRIPTiON OF WORK FEE TYPE OF CONNECTION / LENGTH FROM HOUSE SEWER CONNECTING TO Y _CyJip� P L M L TOP L PUBLIC SEWER @ $ 5 00 �O / PC NO SEPTIC TANK EE GE PIT OR CO IMP IMP NO JOB NO O PITS AND/OR DRAINFIELD C $10 00 U HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO PRIVATE DISPOSAL SYSTEM @ $ 3 00 CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EAS[MENT RECORD INSTR NO DATE WORK TO HOUSE SEWER @ $ 3 0000 R R A AND N HOUSE SEWER OR DISPOSAL SYSTFM C $ 3 00 HWY OR ST WIDENING d EXTN CESSPOOL MANHOLE @ $ 5 00 h STATE ENCROACHMENT I PERCOLATION TEST @ $ 5 OG PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT $ 21 00 AUTHORIZATION TOTAL FEE O CONNECTION CHARGE FEE I 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 SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER r�r OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK SEEP PIT(S) I 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 LO NGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM TH L AL OWNER OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE ABOVE DESCR E RE DENTIAL PROPERTY ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ OF PERMITTEE ❑ SEEP PIT ❑ S) CESSPOOLS /VALIDATION CK ,) M O CASH 0 3 3 1-0 AUG 28 1 0 D 1 0.00