HomeMy Public PortalAbout5931 CLOVERLY AVE_Sewer__ E808 D
CAPPLICATION FOR PERMIT
eeoe a sa COUNTY OF LOS ANGELES
SEWER-SEWA E DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DnnSION BUILDING
JOHN A LAMBIE. County Fmguaeer ADDRESS
CASSATT D GRIFFIN, Sup t of Builduag LOCALITY
EAREST
FOR APPLICANT TO FILL IN CROSS
NNEAR
LEGAL OWNER G, P
DESCRIPTION LOT NO
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE
BUILDINGS BK ISTRICT NO GROUP MAP P6 PROCESSED BY
CONTRALTO
ADDRESS 4 P/ J, CONNECTION ATA
CITY TEL NOl STATION _I DEPTH
11
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO 'v COUNTY
NO DESCRIPTION OF VryRK FEE
PUBLICWESSECCONNECTING TO @ $S 00
SEPTIC TANK SEEPAGE PIT OR TYPE OF CT10N LENGTH FROM
PITS AND/OR DRAINFIELD Q $S 00 Y C RB 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 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1 00
ALTER REPAIR OR ABANDONHOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM 1 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERM $ 2 1 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVAL$ a DATE INSPECTOR S SIGNATURE t
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER ,
SIGNED THI __DAY O 19__ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACK WLEDGE THA HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE ORRECT AND AGREE TO COMPLY_ CESSPOOL❑ DRYWELL
WITH ALL COUNTY ORDINAN AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT!? PROPERTY BACKFILL SEPTIC TANKS❑
/7 �' SEEP PITS ❑ CESSPOOLS
SIGNATURE
OF PERMITTE
Or VALIDATION ROBERT A WOOD _
CK 11 0 CASH SUPERVISING MECHANICAL ENGIN,EgE�R, -PIA.