HomeMy Public PortalAbout6033 CLOVERLY AVE_Sewer__ E 6D
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APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
COI3IIty Of LOS Angeles ADDRESS G r,
JOHN A LAMBIE COUNTY ENGINEER
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST
LEGAL �:7D _3OWNER
DESCRIPTION LOT NO
MAIL
BLOCK TRACT b ADDRESS
NO OF BLDGS rj
SIZE OF LOT NOW ON LOT CITY TEL NO i
USELDFNGS O DISTRICT NO GROUP MAP
BK PG
CONTRACTOR G l S
ADDRESS CONNECTION DATA
STATION 3 1 S DEPTH
72,CITY / TEL NO MANHOLE REFERENCE ry
/�
STATE 4 jL LOWER
REGISTRATION NO 6� COUNTY
NO DESCRIPTION OF WOR FEE
TYPE OF CONBECTION LENGTH FROM ,/r
HOUSE SEWER CONNECTING TO S/'y Y P L M L TO P L `,.'
PUBLIC SEWER @ $3 50 0
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP NO !OB NO
�r
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT NOJ�/
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT g 1 00
AUTHORIZATION I TOTAL FEE
N SU REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS _ DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER .z Gpr
SIGNED THIS DAY 0 a 19 CONNECT ADDITIONAL
OWNER OR /�,� BUILDING OR WORK
OWNERS AGENT - J;` ��� "'"�� SEPTIC TANK SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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 REGIST D AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNT NO STATE ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM THE LEG OWN OF THE AB E
DESCRIBED RESIDENT PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) [-ICESSPOOLS
OF PERMITTE
JOHN A LAMBIE CO Y ENGINEER IDATIO ROBERT A WOOD CHIEF PLBG INSPECTOR
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