HomeMy Public PortalAbout5809 CLOVERLY AVE_Sewer__ C, 7-Y
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APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A LAMBIE County Engineer
WILLIAM A JENSEN Sup t of Building
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NEAREST
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OR APPLICANT TO FILL IN `ROSS ST `
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ION LOT NO .JQ dTLOT OWNER /j Q �j����
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TRACT ADDRESS
NO OF LDGS
LOT NOW ON LOT CITY TEL NO
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OR ` . j mry�sfJ� o. .0 0 Lbqip 4�/�,G ayG CONNECTION DATAC/J7 ,le LI/ TEL NO ".5- 7% `g STATION 4_3DEPTH
�� STATE MANHOLE REFERENCE " / //OUPPER
REGISTRATION NO L� tel" COUNTY aU �7
NO DESCRIPTION OF WORK FEE TYPE OF ECTION LENGTH FROM
HOUSE SEWER CONNECTING TO o 0 Y CURB P L M L TO P L
PUBLIC SEWER C� SS 00
NK / P C NO
SEPTIC TASEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ S1000 CO IMP NO JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO /! V
PRIVATE DISPOSAL SYSTEM @ $300 /" {U d'
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIVEN EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $300 O D
OVERFLOW SEEPAGE PIT DRAINFIELD 17J
EXTN CESSPOOL DRYWELL MANHOLE @ SSOO
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ 53 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 Oo CHARGES
AUTHORIZATION TOTAL FEE /Q OQ CONNECTION CHARGE FEE
1HAVE 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 D Y F �� 19e
OWNER OR ��1 NEW HOUSE SEWER
OWNERS AGENTCONNECT ADDITIONAL
ADDRESS
/ BUILDING OR WORK
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 COUNTYORDINANCES 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 HE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE S IBED R:;��OPERTY ABANDON HOUSE SEW ER
SIGNATURE r
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
TN
SEEP PIS) ❑ L CESSPOON�� J
LIDATION ROBERT 'A "W60D '
SUPERVISING MECHANICAL ENGINEER
CK M O CASH /
L'1Lj 7 1 8 51 DEC(31 1 0 D 1 0.00-