HomeMy Public PortalAbout5818- 5818 1/2 CLOVERLY AVE_Sewer__ DEPARTd3MgT OF COUNTY ENGINIMM SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELESBUILD
WILLIAM J. FOX, COUNTY ENGINEER I ADD EISS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING r a NEAREST V
ADDRESS CROSS ST
LOCALITY DISTRICT NO Ready for Inspection PERMIT NO C
NEAREST S
CROSS ST i
R CEI ED BY / DATE I IS UE BY DATE
OWNER OCCUPANCY MAIL
ADDRESS �b
QQ , USE ZONE BK MItP PO
CITY t G TEL.NO Rr I
CONTRACTOR , C�fJ�4�c °
CO IMP NO � /I
ADDRESS JOB.NO —t
CITY TEL NO Q� Al SV 70 TRUNK PERMIT NO
REGISTRATION NO ��3��3` �_ 5C� B STATE
COUNTY ROAD PERMIT NO
LEGAL /�nn STATE ENCROACHMEN
11 T
DESCRIPTION LOT NO o� PERMIT NO
BLOCK TRACT 41 & ! INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT ,SQ NO OF NOW ON LDTS 13 CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEES
PUBLIC SEWER 0 $ 8 50 RECEIPT NO I ATE I BY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR EXEPTIOlMkECORDED
_ WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING I DAT I BY
_ SEWER OR DISPOSAL SYSTEM 100
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR _ /7
_ PITS AHD/OR DRAINFIELD 200 STATION DEPTH 1--
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 MANIHOLERREFERENCE LOWER
TYPE OF CONNECTION LENGTH FROMs-6
-y- --Gu t•B—"-- :.: --M-L TO P I f' »��—
OWNERS PERMIT T$ I on � ,�- �U s.2/ ~�
AUTHORIZATION TOTAL FEE Fig—ST-i.-
iR—Sgi. �cr,"
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED rw
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INS�hECT R S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS _—DAY OF __ Iq_ NEW HOUSE SEWER 1 sc
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _ _ _ _ _ _ _ _ _ _ _ _ BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
CAITHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL❑ DRYWELL
ION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE � �� SEEP PIT(S)� CESSPOOLS
OF PERMITTEE i
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