HomeMy Public PortalAbout6027 CLOVERLY AVE_Sewer__ 6A642 0-63 APPLICATION FOR PERMIT
76A642D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Building
LOCAL.TV
NEAREST
FOR APPLICANT TO FML ILN CROSS ST
LEGAL /'� f
DESCRIPTION LOT NO ( f,J OWNER
MAIL
BLOCK TRACT ADDRESS
l NO OF SLOGS 17
SIZE OF LOT NOW ON LOT CITY ( TEL NO
USE OF DISTRICTNO GROUP MAP PROLE D BY
BUILDINGS 90
S, 0 4K �S
CONTRACTOR
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ADDRESS19 *1L 10 CONNECTION DATA
CITY TEL N ���
STATIONT DEPTH !
O !(f
/,y) STATE MANHOLE REFERENCE
REGISTRATION NO 109(J LJ COUNT I / LOWE
NO DESCRIPTION OF WORK FEE TYPE OF TION LEN TH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TO P L
PUBLIC SEWER @ $5 00 (JJPC NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO 7 JOB NO O
PITS AND/OR DRAINFIELD @ SIO 00 V
HOU 5E SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT N
PRIVATE DISPOSAL SYSTEM @ S3 00 O� m
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER I EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD 17.1
EXTN CESSPOOL DRYWELL MANHOLE @ $500
HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE h
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00
AUTHORIZATION TOTAL FEE 07
/ CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGE
SIGNED THIS DAY OF 19_ ....- f
OWNER OR NEW HOUSE SEWER „y. F ll
OWNERS AGENT441 A
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE RE D THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT A D AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFLB
AM PROPERLY GI ERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUOS LINTY AND STAT OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THL GAL ER OF AND INT TO DISCONNECT PLUG AND
RESIDE IN T ` BE RE EN IAL ERTY ABANDON HOUSE SEWER
SIGNATURE ❑ Q
OF PERMITTEE BACKFILL SEPTIC TANKS V�
SEEP PIT(S) ❑ CESSPOOLS
LIDATI ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
M O CASH
( o b 3 UN 14 1 0 D 7.0 0
y�Oar may/