HomeMy Public PortalAbout5945 CLOVERLY AVE_Sewer__ D
CESoa APPLI ATIOIV FO PERMIT
eeoe a as COUNTY OF LOS ANGELES ,.
SEINER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
rrOHM A LAMBIE, County Ea eer ADDRESS
CASSATT D GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FUI IN CROSS ST
LEGAL OWNER
DESCRIPTION LOT NO
BLOCK TRACT MAIL
ADDRESS
NO OFBLDGS
SIZE OF LOT�IS NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS VA 19
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL NO �S� STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION N !� COUNTY12
No I DESCRIPTION OFWORK' FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 0-0
SEPTIC TANK SEEPAGE PIT OR TYPE OF TION LENGTH FROM /S
PITS AND/OR DRAINFIELD @ $3 00 Y CURB P L M L TO P L ��CJ
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
WORK CT ADDITIONALOUSE LDG OR @ $I 00 TRUNK PERMIT NO ROAD PERMIT NO
ALTER
OR DISPOSAL R A ANSYSTEM DON HOUSE @ $1 OO STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'.S PERM $ 1 21 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 F 0 REIMBURSEMENT FEE ,(/ ,/ es
pj 5- �atH1_ t�Pr
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- /�D !97
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER �} A
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS GE A BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I AVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CqFRRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IC HEREBY 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 I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENAL PRO ERTY BACKFI LL SEPTIC TANKS ❑
SEEP PITS) ❑ CESSPOOLSVIL
SIGNATURE
OF PERMITTEE
Or VALMATIOROBERT A WOOD
CK M 0 CABR SUPERVISING MECHANICAL ENGINEER
L, 0h Go h' 191 0 D 5LO P