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HomeMy Public PortalAbout6003 CLOVERLY AVE_Sewer__ CE808-D APPLICATION FOR PERMIT ceaoe•s-se COUNTY OF LOS ANGELES P`! 9 �!i SEWED—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ADDRESS JOHN A. LAMBIE, County Engineer CASSATT D. GRIFFIN, Sup't of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST. FP F1 LEGAL f L Q OWNER DESCRIPTION LOT N0. BLOCK TRACT MAIL ADDRESS SIZE SIZE OF LOT�7�Q /i w NOW OFN LOTS CITY TEL. N0. USE OF BUILDINGS DISTRICT N0. GROUP BK MAP P CESSE ���Y���yyy , CONTRACTOR f 6/I ADDRESS CONNECTION DATA CITY TEL.NO. STATION DEPTH STATE MANHOLE REFERENCE UPPER REGISTRATION NO. COUNTY LOWER `. No. DESCRIPTION OF WORK FEE t HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $3.00 SEPTIC TANK,SEEPAGE PIT OR TYPE OF NECTION LENGTH FROM PITS AND/OR DRAINFIELD @ $3.00 _ Y. C RB P.L. M.L.TO P.L. OVERFLOW SEEPAGE PIT, DRAINFIELD EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $2.00 HOUSE SEWER CONNECTING TO P.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 ABANDON HOUSE STATE ENCROACHMENT DISPOSAL SYSTEM @ $1.00 'T PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OVINER'oS° PERMIT $ 2 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON_ APPROVAL DATE INSPECTOR'S SIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. SIGNED THIS DAY OF 19— NEW.HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK SEPTIC TANK,SEEP,PIT(S) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION Y AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM 1 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 BACKFILL SEPTIC TANKS❑ DESCRIBED RESIDENTIAL PROPERTY. r 7-7,-!�; / } SIGNATURE SEEP.PITS El CESSPOOLS l7 ��\t 7j /� OF PERMITTEE- OF ERMITTEE OF VALIDATIONROBERT A.WOOD CK. M.o. ,cAiH SUPERVISING MECHANICAL ENGINEER -,Eo 5 8 9 I Ln t'PR 29 1 0 A 3.00 m F608 D ceeoe APPLICATION FOR PERMIT COUNTY COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING /�3 A/ t ))OHN A I.AMSIE, County Engineer ADDRESS l CILSSAIT D GRIFFIN Supt of Su�I q i LOCALITY FOR A;,Sw FILL IN NEAREST LEGAL DESCRIPTION LOT NOWNER BLOCK TRACMAILADDRESS/� LDGSSIZE OF LOT LOTASTATE CITY TEL NO��USE OFBUILDINGSDISTRICT NO GROUP MAP CONTRACTOR �K �'P6ADDRESS CONNECTION DATA CITY STATION ��7�Jp DEPTH UPPERREGISTRATION NO — MANHOLE REFERENCE R No DESCRIPTION OF ORK FE + HOUSE SEWER CONNECTING TO _ PUBLIC SEWER TYPE OF ION LENGTH FROM / SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TOP L ITS AND/OR DRAINFIELD @ $3 00 OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE @ $2 00 HOUSE SEWER CONNECTING TO P C NO PRIVATE DISPOSAL SYSTEM Q $1 00 CO IMP NO JOB NO CONNECT ADDITIONAL BLDG OR WORK TO HOUSE SEWER @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO ALTER REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM @ $1 00 STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL r i CHARGES OWNER'S PERMIT $ QO CONNECTION CHARGE FEE AUTHORIZATION I TOTAL-FEE A REIMBURSEMENT FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON y TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE- TO THE PUBLIC SEWER ©� ��j _ / SIGNED THIS 16+ DAY OF "'�/ 19L_ NEW HOUSE SEWER - .h' OWNER OR-- //jr CONNECT ADDITIONAL OWNERS AGE T10 ��' L �"-��"T BUILDING OR WORK ADDRESS - -- - - �` - - SEPTIC TANK SEEP PIT(S) AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION AND STATE THAT_THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS EGULATING PLUMBING AND SEWERS ALTER REPAIR SEWER OR SEWAGE DISPOSAL SYSTEM I-HEREBY—CERTIFY THAT I AM-PROPERLY-R ISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRE Y LOS ANGE CO TY AND STAT F ABANDON HOUSE SEWER CALIFORNIA OR THA AM THE_ 0 MER/fi"TIIE VE — - DESCRIBED RESIDEN PROPERTY BACKFILL SEPTIC TANKS❑ SEEP PIT(S) ❑ CESSPOOLS ❑ SIGNATURE T OF PERMIT L-V ®R0 ALIDROBERT A WOOD - - CK to o (`.+.'.CASH// SUPERVISING MECHANICALENGINEER_ - - - LAC0 4 0 6 r°� 5 1 0 A 5.00