HomeMy Public PortalAbout6019 CLOVERLY AVE_Sewer__ CE808 3 64 �Y
76A642D APPLICATION F R PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAG DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING Q/
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t o4 Building `
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL S Y
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP 4MAP PROCESSED BY
K PG
CONT RACTO /S7���
ADDRES CONNECTION DATA
7Y TEL NO 9 STATION �/} DEPTH
{ STATEMANHOLE REFERENCE
REGISTRATION NOIAI �/ COUNTY ,df-7LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CO TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y RB P P L M L TO
PUBLIC SEWER @ $5 00 OO
SEPTIC TANK SEEPAGE PIT OR PC NO
PITS AND�OR GRAINFIELD $10 00 CO IMP NO JOB NO d
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIV[Y [ASrMllIT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $300 `
OVERFLOW SEEPAGE PIT DRAINFIELD
E%TN CESSPOOL DRYWELL MANHOLE @ $500 VVV
ALTER REPAIR OR ABANDON HOUSE HWV OR ST WIDENING 92-
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT N
PERMIT NO z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S 2 OO CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITHE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DES I D EXISTING DWELLING
TO THE PUBLICSE R APPROVALS OfTE INSPECTOR 5 SIGNATURE
SIGNED THIS DAY,113P I--
OWNER
OWNER ORNEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANKSEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAI NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
i HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIREDAY LOS ANGLES COUNTY A STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 ��EGAL OWNEROFA NTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABO DESD R I ENTIA4 P RTY ABANDON HOUSE SEWER
SIGNATURE �y
OF PERMITTEE BACKFILL SEPTIC TANKS ❑ ,
SEEP P ❑ CE35POOL
VALMAT16N ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
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