HomeMy Public PortalAbout6042 CLOVERLY AVE_Sewer__ CA64276A842D
2 APPLICATION FOR PERMIT
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 BuEldmg
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN =ROSS ST
LEGAL
DESCRIPTIONLOT NO (� OWNER
MAIL
BLOCK TRACT ~ ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
/BK PG
CONTRACTOR (,l�F �L.. Lr
ADDRESS % JJ CON/NECTION DATA
CITY TEL NO STATION '' S DEPTH
E MANHOLE REFERENCE ✓ UPPER
REGISTRATION NO COUNTY
NO DESCRIPTI OF WORK FEE I TYPE OF CONNECTION LENG4FR
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ E5 00 Ij(V�!'•
SEPTIC TANK SEEPAGE PIT OR P C NO
PITS AND/OR DRAINFIELD @E I O 00 CO IMP NO JOB NO `
HOUSE SEWER CONNECTING TO TRUN D PERMIT NO �.
PRIVATE DISPOSAL SYSTEM 0 $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT AIME EASEMEN RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ E3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM Q E3 00 STATE ENCROACHMENT
PE_RMITX 40
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT t 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
BU LDING OR WORK 'S
ADDRESS Com•,..�` ,.
SEPTIC TANK�S�EP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LAOGLES COUNTY AND TATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THA T E L AL OWNER AN TEND TO DISCONNECT PLUG AND
RESIDE IN THE VE R D DENT PRO TY ABANDON HOUSE SEWER
SIGNATURE (-
BACKFILL SEPTIC TANKS ❑
OF PERM? SEEP PITS) ❑ CESSPOOLS ❑
ALIDATION ROBERT A w000
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
1
JAL 15 :l u 0 5
24650 INSERTS '
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CE80888D APPLICATION FOR PERMIT -
78A842D COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER BUILDIN /� V/�
BUILDING AND SAFETY DIVISION ADDRESSG �, T
JOHN A LAMBIE County En neer
LD I
WILLIAM A JENSEN Supt of Building LOCALITY F
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL / OWNER
DESCRIPTION LOT NO
BLOCK TRACT MAIL
!! ADDRESS t
NO OFBLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
OF
BUILDINGS DISTRICT NO RR MAP PROCESSED BY
I BK PG
CONTRALTO { � �— ��'
i
ADDRESS CONNECTION DATA
CITY TEL NO STATION , �} DEPTH
/ STATE MANHOLE REFERENCE UPP
REGISTRATION NO "'--' COUNTY
NO DESCRIPTIlDN OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF ION LENGTH FROM f
PIETS AND/OR DRAEINFPTIC TANK GELDPIT
OR @ S3 00 Y CURB P L M L TO P L
i
OVERFLOW SEEPAGE PIT DRAINFIELD -
EXTN CESSPOOL DRYWELL @ S2 00
HOUSE SEWER CONNECTING TO PC
NO
PRIVATE DISPOSAL SYSTEM @ S1 00 CO IMP NO JOB NO y,
CONNECT ADDITIONAL BLDG ORTRUNK PERMIT NO ROAD PERMIT NO V
WORK TO HOUSE SEWER @ $1 00
SEWER OR DISPOSAL AL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT _ pq
PERMIT NO O+
INDUSTRIAL '
WASTE APPROVAL W
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON _ i
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
SI THE PUBLIC SEWER
_SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
NECT
OWNERS AGENT BUILDING ORDWORKAL '
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS.APPLICATION,
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRY-WELL ❑
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
DESCRIBED RESIDE AL PROP Y BACKFILL SEPTIC TANKS ❑ 12,SIGNATURE
SEEP PIT(S) [:1 CESSPOOLS l/
OF PERMITTE offl - G
OF VALIDATION ROBERT A WOOD
!d
CK o CASH SUPERVISING MECHANICAL,ENGINEER _
M
LAr�, �r
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