HomeMy Public PortalAbout5954 CLOVERLY AVE_Sewer__ 6AG42D°'E2
7APPLICATION FOR PERMIT
78A 842
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ..ter S
JOHN A LAMBIE County Engineer ADDRESS/� D
WILLIAM A JENSEN Sup t of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST _
LEGAL
DESCRIPTION LOT NO OWNER L4 41L
I MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
BK PG
CONTRACTOR It T 1' "l J
L
ADDRES CONNECTION DATA «l
TY TEL NO ! a STATION DEPTH
C
STATE UPPER
�ANH`O E t�
REGISTRATION NO �� COUNTY ✓W �!
NO GESCRIP ION OF WORK FEE TYPE OFC N CTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y URB P L M L TO P L O
PUBLIC SEWER @ $5 00
C NO V
SEPTIC TANK SEEPAGE PIT OR
J
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO OB NOix
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO O
PRIVATE DISPOSAL SYSTEM @ $300 R
CONNECT ADDITIONAL BLDG OR �O AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE U
WORK TO HOUSE SEWER @ $300 LU
LU
OVERFLOW SEEPAGE PIT DRAINFIELD H
EXTN CESSPOOL DRYWELL MANHOLE @ 55 00 Z
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 21 00
AUTHORIZATION TOTAL FEE /0100
CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HER IN NAMED CON REIMBURSEMENT FEE
TRACTORPT PUBLIC
CONNECT THE ABOVE DES R�'D E) TING DWELL! APPROVALS
THE DATE lNSP OR 5 SI ATURE
SIGNED THIS D 19
OWNER OR NEW HOUSE SEWER j
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I THE L GAL OWNER Ot�E
INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABO ESCRI D RESIDENTIALRTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ElOF PERMITTEE ❑
SEEP PIT(S) ❑ CESSPOOLS
VALIDATIO( 1 ROBERT A WOOD
CK M o '-ASS) SUPERVISING MECHANICAL ENGINEER
l`
Lrt�,o 5 5 2 6- FEB 1 j 1 0 D 1 0.0 O N