HomeMy Public PortalAbout5934, 5934 1/2, 5936 CLOVERLY AVE_Sewer__ r 42
S&ED APPLICATION FOR PERMIT
6 1
6&E 63 12 54
DIVISION OF BUILDING AND SAFETY SEWER-SEW E DISPOSAL
Deportment of County Engineer
County of LOS Angeles BUILDIAD-RENG
WM J FOX, COUNTY ENGINEER J
CASSATT D GRIFFIN SUP T of BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
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LEGAL CROSS ST�3
DESCRIPTION LOT NO -y / OWNER
BLOCK TRACT r� / MAIL
l ADDRESS
SIZE OF LOT J NOW ON LOTNO OF S CITY N �Q� /�` TEL NO �
USE OF
BUILDINGS V DISTRICT NO GROUP 'MAP
BK PG
CONTRACTOR �� / j'S3
ADDRESS 0113 1 "ekt zy _y- CONNECTION DATA 4~
CITY TEL NO STATION --SiS� DEPTH 6
EV STATE 6 MANHOLE REFERENCE
REGISTRATION NO "� ElCOUNTY '- 4 LOWER
zl/o z� ./y 1 k TYPE OF CONNECTION LENGTH FROM
j�o
NO DESCRIPTION OF WORK FEE rnRR P L r, M L TO P L '
HOUSE SEWER CONNECTING TO O
PUBLIC SEWER @a $ 3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG ORCO IMP NO JOB NO
WORK TO HOUSE SEWER 1 00 �.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 C4ARGES
CONNECTION CHARGE FEE
OWNERS PERMIT g 9, 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT
�FEE
TRACTORHAVE TTOS CONNECT O THEA
ABOVECTED WDESCR BEDITH THE HER
EXESNINGA DWELLIED NG APPROVALS DATE INSPECTOR SSIGNATURE
TO THE PUBLIC`SEW R _
SIGNED THIS DAY OF /t�a NEW HOUSE SEWER 2 5Jr A
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
I /A-
THEREBY
SEPTIC TANK SEEP, PIT(S)
ADDRESS AND/OR DRAIhFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WI(H ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI L PROPERTY BACKFILL SEPTIC TANKS 11
SEEP PIT S ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTE
WILLIAM J FOX, COUNTY ENGINEER VALIDATION
BY I' AgY2 2.5 'FfB 4 4,.�-. 6_ .5_
DEPUTY '� DEPUTY -
BY BY
® DEPUTY DEPUTY