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Home My Public Portal About5909-5927 CLOVERLY AVE_Sewer__ 76A642D � CE 8081REV.6/781 ©s APPLICATI I N FOR E RM IT SEWER - SEWAGE DISPOSAL COUNTY OF LOS ANGELES ,BUILDING AND SAFETY FF R APPLICANT TO FILL IN DISTRICT NO. GROUP BK MAP PROCESSED BYBUILDINGPGADDRESSLOCALITY G �� L CONNECTION DATA NEARESTS STATION / -1 �l✓ DEPTH CROSS ST. ( T - ., UPPER MANHOLE REFERENCE LOWER OWNER J TYPE OF CONNECTION LENGTH FROM MAIL / Y. CURB P.L. M.L.TO P.L. ADDRESS 2- � P.C.NO. CITY 1y� t TEL.NO.- S s't-S CO.IMP.NO. JOB NO. t. LEGAL TRUNK PERMIT NO. ROAD PERMIT NO. �o DESCRIPTION LOT NO. AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE BLOCK TRACT NO.OF BLDGS. SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING USE OF BUILDINGS STATE ENCROACHMENT PERMIT NO. _ may'' ,p INDUSTRIAL C NAC TRTOR ' v�.,I-- Gp� G WASTE APPROVAL ADDRESS G CHARGES CONNECTION CHARGE FEE CITY ^� �7 TEL.NO. STATELICENSE NO.3 C 3 Z Li 1 CLASS - REIMBURSEMENT FEE Q NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE HOUSE SEWER CONNECTING TO O /— PUBLIC SEWER O p NEW HOUSE SEWER SEPTIC.TANK.SEEPAGE PIT OR PITS AND/OR DRAINFIELD CONNECT ADDITIONAL U HOUSE SEWER CONNECTING TO BUILDING OR WORK L4SSJJ PRIVATE DISPOSAL SYSTEM SEPTIC TANK,SEEP,PIT(S) CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD WORK TO HOUSE SEWER o OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL[EllEXTN.,CESSPOOL.DRYWELL.MANHOLE ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR.SEWER OR SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER BACKFILL SEPTIC TANKS❑ - Perm it $ SEEP,PIT(S)❑ CESSPOOLS OWNER'S ❑ AUTHORIZATION TOTAL FEE VALIDATION I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- - TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SE''�WERR. 1 G (� yr/ SIGNEDTHIS - DAY OF J 19�� 3 Q jd s �j'� �3511.9 p OWNERS ^/fin ,(��d 4-r� •�� ,f' 'i OWNERS AGENT] - G # 0000'.10 ADDRESS p I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 2 0 0 1 C?o o AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. - ,O O 'O p 1 ° O O rj I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO RE- 0625-79 SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL 1 PERTY. SIGNATURE 112 OF PERMITTEE