HomeMy Public PortalAbout6048 CLOVERLY AVE_Sewer__ 9 B E-883 3.58 APPLICATION
DIVISION OF BUELDING AND SAFETY SEW E Fd®SEWA(�E DISPOSAL
Department of County Engineer _
County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY C..NEARESLEG1
FOR APPLICANT TO FILL IN CROSS ST
DESCRIPTION LOT-NO 0� �� �- ,OWNER
BLOCK TRACT, /�/,y/ MAIL.
ADDRESS
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ASIZE OF LOT � /�� NOW ONBLOTS f 'CITY l �Tj TEL NO 41'—
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USE OF
BUILDINGS ,/j ..L DISTRICT NO.1, GROUP BK"MAP PG1
CONTRACTOR'/ • .elm ,� ���
ADDRESSr1/1 a .,er CONNECTION DATA
CITY .a0TEL N�^^i°• , STATION DEPTH •G
A/ MANHOLE STATE MANHOLE REFERENCE UPPER
REGISTRATION NO � >� ❑ COUNTY
NO DESCRIPTION-OF WORK FEE
•HOUSE SEWER CONNECTING TO TYPE OF RBYG-OECTION 'LENGT4 FROM
PUBLIC SEWER Q $ 3 50 _CURB/ drf5 M L TOP L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00 —
CONNECT ADDITIONAL BLDG OR3 P C NO
WORK TO HOUSE SEWER 1 00 ,CO IMP NO /f�J J09 NO
ALTER OR REPAIR EXISTING '
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO- ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM, 1 00 PERMIT NO
'SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 'INDUSTRIAL
WASTE APPROVAL
CESSPOOL-DRYWELL
SPECIAL C014DITIONS ONLY 2 00 CHARGES
'CONNECTION CHARGE FEE
OWNER'S PERMIT g 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT 1;�E� r
TRACTORHAVE TTOS DATE CONNECT THE ABOVEWITH THE DESCR BED EXIST)INGA DWELLING I APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SE c — -
SIGNED THIS DAY OF /J NEW HOUSE SEWED, �` 9
,CONNECT ADDITIO
OWNERS AGENT
'OWNER OR �, -j� ZI BUILDING OR WORK
_ -
v SEPTIC•TANK, SEEP, PIT(S) -
ADDRESS 'AND/OR DRAIN FIELD
1 HERCBY-ACKNOWLEDGE THAT I HAVE READ- APPLICATION CESSPOOL❑ DRY-WELL❑
AND STATE THAT THE ABOVE IS CORRECT AND REE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR
PLUMBING 'AND SEWERS - SEWAGE DISPOSAL SYSTEM -
1HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR -
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND - -
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE 'ABANDON HOUSE SEWEP-
DESCRIBED RESIDENTIAL PROPERTY. _"BACKFILL SEPTIC TANKS❑ l ,¢
�� +� } SEEP.,PIT(S ❑, CESSPOOLS I9 1'FaB
SIGNATURE �„� e5... ��' /_ta
OF PERMITTEE � �
rT 'cam',
WILLIAM J. FOX,COUNTY ENGINEER VALIDATION R.A.WOOD. CHIEF PLBG.`INSPECTOR
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