HomeMy Public PortalAbout5826 CLOVERLY AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING ll
ADDRESS ���a C1["14Pt�1l�l
FOR APPLICANT
AP/PLICANT TO FI L IN LOCALITYBUILDING
NEAREST
ADDRESS CROSS ST
LOCALITY DISTRICT NO SERIAL NO PERMIT NO c
NEAREST �� A S
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CROSS ST
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
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MAIL USE ZONE OCCUPANCY MAP
ADDRESS BK PG
CITY TEL NO
_ t
CONTRACTOR . CO IMP NO
ADDRESS �!/ JOB NO _
CITY TEL 0 TRUNK PERMIT NO �^
OR- STATE
REGISTRATIO NO COUNTY ROAD PERMIT NO
LEGAL- STATEENCROACHMENT
DESCRIPTION LOT NO G PERMIT NO
BLOCK TRACT INDUSTRIAL
KASTE APPROVAL
SIZE OF LOT_ro K NOW ON NO OF LOTS CHARGES
USE OF
BUILDINGS ��1J L % CONNEC CHARGE FEE
NO DESCRIPTION OF1 WORK VtE
HOUSE SEWER CONNECTING TO REIMBURSEMENT F
PUBLICSEWER @ $ 350 .3 S-40 RECEIPT NO DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
J-7 CONNECT ADDITIONAL BLDG OR / EXCEPTION RECORD
DEWORK TO HOUSE SEWER _,' 100- / 00
e NO ALTER OR REPAIR EXISTING I DATE
_SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
-- AND/OR DISPOSAL SYSTEM , '' - 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 200- _ STATION 3.� 3 ��' DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 101_ Q MAC PLREFERENCE
'jiJ TYPE OF CONNECTION ER' LENGTH FROM /
.� .�Bl�R8_ �/P L M LTO P L
OWNERS PERMIT $ I 00
-AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE/PUBLIC SEWER
SIGNED THIS �'1 DAY OF _ _ I Y NEW HOUSE SEWER o r L -z 3-
OWNER OR �� - CONNECT ADDITIONAL `
OWNERS AGEN _ _ BUILDING OR WORK `
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1AVE READ HIS APPLI -CESSPOOL[:] DRYWELL E]r ,CATION AND STATE THAT THE ABOVE IS NORREC AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
' 1 HEREBY, CERTIFY T AT I AM P OPERLY REGISTERED DISCONNECT PLUG AND
AHD/OR LIC NSED-AS RE UIRED B �OS-ANG�,.EELES COUNTY ABANDON HOUSE SEWER
AND STATE A ORN I AM THE)LEGAL OW -
ER OF I %�Y`V DESC S D L E� Y7� BACKFILL SEPTIC TANKS
-� SEEP PIT(S)o CESSPOOLS
SIGNA � _
OF PE EE
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