HomeMy Public PortalAbout5938 CLOVERLY AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1
..DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY , CO ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING d�`v�e
ADDRESS -0 'y�+
FOR APPLIC NT O FILL IN LOCALITY
ABUILDING DDRESS d NEARES
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LOCALITY DISTRICT NO SERIAL NO PERMIT NO C
NEAREST ` A ! 7 �� �� S
CROSS ST
�� V� RECEIVED BY Ready for Inspection D Z ��..�
OWNER MAIL \ �e r O (J
AD KESS �A V 1�I ' / Q (' P Y 1 USE ZONEV OCCUPANCY BK
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CITYTEL NO I � �
CONTRACTOM. C NottingthIm Co of TempleW--
CO IMP NO 6
ADDRESS 5933 N CLOVERLY AV
JOB.NO
CITY TEL NO. TRUNK PERMIT NO
740e STATE
REGISTRATION NO �/ ® COUNTY
ROAD PERMIT NO
- LEGALn
DESCRIPTION LOT NO `� STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT S .Cj INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT �d Xi 7� NO OF NOW ON LOTS ` CHARGES
USE OF
BUILDINGS C-0 CONNECTION CHARGE EE
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLICSEWER t@ $ 350 RECEIPT NOI DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR /1 EX PT N RECORDED
WORK TO HOUSE SEWER 1 00 0 NO DATE BY
ALTER OR REPAIR EXISTING
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 DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS ; I do
Y CURB P L M L TO P L
PERMIT
AUTHORIZATION I TOTAL FEE O�
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 DAY OF _ �T_ 1 NEW HOUSE SEWERS -�7G,p
OWNER OR - CONNECT ADDITIONAL
OWNERS GENT _ _ _ BUILDING OR WORK
SEPTIC TANK,SEEP PIT(S)
ADORESSADDRESS�D_ AND/OR DRAINFIELD
t HEREBY ACKNOWLEDGE THAT I H VE READ THI APPLI. CESSPOOL[] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RE ENTIAL PROPERTY BACKFILL SEPTIC TANKS E]
i
SIGNATURE SEEP PIT(S)o CESSPOOLS o
, -
OF PERMITTEE _
76A642A 663 7/53