HomeMy Public PortalAbout5829 CLOVERLY AVE_Sewer__ 76AG42D APPLICATIONCES08 11-57 FOR
®E R M1g�
COUNTY ,
OF LOS ANGELES SEWER=SEWAGE. DISPOSAL
DEPARTMENP OF COUNTY ENGINEER
BUII.DING AND SAFETY DIVISION BUILDING
JOHN A LAMSIE, CountF Eng�aeer ADDRESS L "/ J / v✓L'
CASSATI' D GRIFFIN Sup! of Build-g I r�
x LOCALITY
FOR APPLIC T TO FILL IN CROSS T ._-�p''/n,e ''1Y'tC>,,4\
LEGAL — 5 �! OWNER �..Gr /'Y[G
DESCRIPTION L 0 1 C.-`
BLOCK TRACTMAIL
- ADDRESS
NO OF BLDGS _
SIZE OF LOT x NOW ON LOT CITY TEL`NO'
USE OF
BUILDINGS F DISTRICT NO GROUP MAP
- BK PG
CONTRACTOR � �""�/jw r
�o&6
ADDRESS /► .S rSgjy,, ,I,'p 17 ter► CONNECTION DATA
CITYCl/I�v TEL NO ,/7 T/ / �� STATIONa DEPTH
rr I (�1 L ® STATE MANHOLE REFERENCE i UPPER
REGISTRATION NO /p� / J3 ❑ COUNTY i" LOWER
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER - @ $310
(!(�
SEPTIC TANK SEEPAGE PIT OR TYPE OF ECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $8 00 Y U P L M L TOP L .�
OVERFLOW SEEPAGE PIT DRAINFIELD ,
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00
HOUSE SEWER CONNECTING TOP C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 rco IMP NO �� JOB NO n
CONNECT ADDITIONAL BLDG OR '
WORK TO HOUSE SEWER @ $1 00 o 0 TRUNK PERMIT NO ROAD PERMIT NOf r
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1 00 STATE ENCROACHMENT ,
PERMIT NO
INDUSTRIAL
j' WASTE APPROVAL
CHARGES
OWNERS PERBUT $ 00 CONNECTION CHARGE FEE
AUTHORIZATION ,00w_ - +
REIMBURSEMENT FEE
I HAVE AT THIS DATE A"CONTRACT-WITH THE HEREIN NAMED CON _ "
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE y
TO T_HE PUBLIC SEWER
SIGNED THIS DAY`OF T -_ V 19_ NEW HOUSE SEWER -Z3-
OWNER ORCONNECT ADDITIONAL—^-""
OWNERS AGENT BUILDING OR WORK �Z, «
-SEPTICTANK SEEP 41T(S) -
ADDRESS - - i 'AND/OR DRAINFIELD'
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS_CORRECT-AND AGREE TO-COMPLY -CESSPOOL ❑-DRYWELL El - '-'�`'-�^ -"'•`^`
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS ALTER REPAIR SEWER OR
("`HEREBY"CERTIFY-THAT'I'AM-PROPER LY`REG ISTERED-AND/OR -'SEWAGE DISPOSAL SYSTEM- - l»r'-r-•- -
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE, LEGAL„OWNER_OF THE ABOVE, ABANDON HOUSErSEWER ,-
DESCRIBED RESIDENTIAL PROPERTY _ BACKFILL SEPTIC TANKS ❑
SEEP PIT(S) ❑ CESSPOOLS
SIGNATURE
OF PERMIT_TE
OF VALIDATION _K l"ROBERT"A WOOD -.
CK d 0 cASH SUPERVISING MECHANICAL ENGINEER