HomeMy Public PortalAbout5823 CLOVERLY AVE_Sewer__ j 5.65
76A645-65
APPLICATION FOR PERMIT
76A 64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ^
JOHN A.LA\1BIE, County Engineer ADDRESS /l ff/ v Z`
COLEMAN W. JENKINS,Supt. of Building
LOCALITY L
FOR APPLICANT TO FII. IN NEAREST F �/�"S �IA-)CRO55 ST.AL
DESCRIIEGPTION LOT NO. OWNER I` 4pkMAIL `' (^:{hh/ ry ADDRESS ^ U • v 1SIZE OF LOT/0 UfC NOW OON LOTSO! CITY�,OS STEL. NO.
USE OF
BUILDINGS DISTRICT NO. GRIT
OUP K MAP PG fJ' PROCESSED BY
CONTRACTOR �08 -l 3 7
ADDRESS L (,( �D CONNECTION DATA
CITYTEL. NO. �� STATION Q DEPTH
LICENSE ^ LICENSE ^ ^ v A / UPPER
NO. U /a CLASS S`,�oL/ MANHOLE REFERENCE �/l7/
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 �7
EPTIC TANK, SEEPAGE PIT OR CO.IMP.NO. 1d 0
PITS AND/OR DRAINFIELD $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM $ 3.00
GC
CONNECT ADDITIONAL BLDG, OR AFFIDAVIT wAlvEq EASEMENT RECORD,IN57R,NO. DATE O
WORK TO HOUSE SEWER _ $ 3.00
RE R ANDON HOUSE ~
SEWER OR DISPOSA
,^ $ 3.00 v
W
HWY.OR ST.WIDENING a
N
EXT N.,C ESS POOL, MANI+OLE $ 5.00 STATE ENCROACHMENT Z
I PERCOLATION TEST P $ 5.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 21 Go
AUTHORIZATION rTOTAL FEE " 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 SEW R APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS ;� DAY OF 19,(v-7
OWNER OR NEW HOUSE SEWER _
OWNERS AGENT
_ CONNECT ADDITIONAL 'S
/ BUILDING OR WORK
ADDRESS '
I HEREBY ACKNOWLEDGE T I VE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
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 [I 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, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER .pl'
-
SIGNATUREJY ;�,y JT .� BACKFILL SEPTIC TANKS ElOF PERMITTEE C]SEEP,PIT(S) ❑ CESSPOOLS
VALIDATION
CK. M.O. CASH
LALO 0 2 2 2 iiuG 2 2 1 D 5.00-