HomeMy Public PortalAbout6038 CLOVERLY AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER I 1E1ER--SEWAGE DISPOSAL
a DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
` WILLIAM J. FOX, COUNTY EN131NEER BUILDING
ADDRESS
FOR APPLICANT TO FILL INLOCALITYBUILDING I�I NEAREST y
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LOCALITY f DISTRICT NO NO PERMIT NO
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TEL NO
!/ �� 'TRUNK PERMIT NO
STATE
REGISTRATION NO - T ��/ B COUNTY' ROAD PERMIT NO
LEGAL ��r
DESCRIPTION LOT NU � 7 STATE ENCROACHMENTPERMIT NO
BLOCK TRACTf INDUSTRIAL x
SIZE OF LOT /g NO OF BWASTE APPROVAL
LDGS ys
NOW ON LOT 9� CHARGES
USEOF
BUILDINGS A CONNECTION CHARGE FEE,
i
NO DESCRIPTION OF WORK FEE i
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 350 RECEIPT N^Q,—__.I;_ ___DATE_`—I BY
HOUSE SEWER CONNECTING TO r
PRIVATE DISPOSAL SYSTEM 100 {
CONNECT ADDITIONAL BLDG OR _ d EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00
NOI_
ALTER OR REPAIR EXISTING DATEy I BY
SEWER OR DISPOSAL SYSTEM 1 00 _ y
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 200 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 MANHOLE REFERENCE
UPPER �!
TYPE OFC NNECTION LENGTH FRO
OWNERS PERMIT $ I -1 00 # CURB w"Ptr— ML TOP L
AUTHORIZATION TOTAL FEE 1 i - -
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ADOV DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWE
SIGNED THIS DAY 19 d�P NEW HOUSE SEWER ��� I -Z
OR CONNECT ADDITIONAL
OWNER -
OWNERS O NT BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE RE D THIS APPLI- CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORR CT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES A D STATE LAWS' ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS I SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS
SEEP PIT(S)[3 CESSPOOLS 2, � ��' L A5-
SIGNATURE ,
OF PERMITTEE
76A642D 663 1/53