HomeMy Public PortalAbout5819 CLOVERLY AVE_Sewer__ 6-65
76A645-65
APPLICATION FOR PERMIT {�
76A 64 u
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING r � ) 14 L)ejQ�
JOHN A. LANBIE, County Engineer ADDRESS v L
COLEMAN W. JENKINS,Sup't, of Building � ��'
LOCALITY p , ln try
1
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. �-
DFS
AL
CRGIPTIONLOT NO / U OWNER
MAIL
BLOCK TRACT 6� ADDRESS
SIZE OF LOT /V 0 K l-/u NOWOON LOTS CITY C& C TEL. NO. ���tyt.p''�
USE OF1 �� DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
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CONTRACTOR
M I eF p i rAss i 5, 09 Z L K-/?y
ADDRESS 1,5 tt c .L6 V to % CONNECTION DATA
CITY L TEL. NO. f STATION 7L Qc✓,0 DEPTH
LICENSE LICENSE }rR
N0. -a CLASS MANHOLE REFERENCE /17 N o.,-- LOW ER
NO, DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER $ 5.00
PTI E� PIT OR CO.IMP. NO. J , ✓ / �/ O
PITS AND/ORR DRAINFIELD = $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. (�
PRIVATE DISPOSAL SYSTEM $ 3.00
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. DATE 0
WORK TO HOUSE SEWER $ 3.00
'KUTrR_, REPAIR RARAN N HOUS
SEWER OR DIS POSA $ 3.00 {(jJ'
LOWHWY. OR ST.WIDENING d
_EPAGEEXTN.,CESSPOOL. MA NNOLE - $ 5.00 STATE ENCROACHMENT h
1 PERCOLATION TEST $ 5.00 PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE 4r-.) CONNECTION CHARGE FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC S W RA ,a /�j , i ,T ',, / APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OFtK�l.6" i9 2 r
OWNER OR , V L j�j. p NEW HOUSE SEWER
OWNERS AGENT �fV�i'(,�L(l..GiCYt- CONNECT ADDITIONAL
A DDRESS� ae� BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE TH I 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 ❑ ORYWELL ❑
I HEREBY CERTIFY THATI AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF [�ABAND
SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TOONNECT PLUG AND
RESIDE IN, THE AB VE DESCRI ED RESIDENTIAL PROPERTY.
/9 -R ON HOUSE SEWER
SIGNATURE ' 'OF PERMITTEE L �� FILL SEPTIC TANKS.PIT IS) ❑ CESSPOOLS ❑
VALIDATION
O. CASH
L , 0 2 2 O t hUG 2 2 D 5.0 j s.
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