HomeMy Public PortalAbout6053 CLOVERLY AVE_Sewer__ E.663 3-SS YYD ALICA TION FOR / O_RMI ■ �a-
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DIVISION OF BUILDING AND SAFETY SEWER®SEWAGE DISPOSAL.
Department of County Engineer
County of Los Angeles BUILDING
WM.J. FOX. COUNTY-ENGINEER ADDRESS
CASSATT D. GRIFFIN, SUPP'T OF.BUILDIyN��G LOCALITY A
FOR IC T 1O L 'y� NEAREST
CROSS ST
LEGAL = YJ' �'
DESCRIPTION LOT NO 'OWNE
BLOCK 'TRACTS �j A1 L
ADDRESS jr,
` NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP
BK - PG
CONTRACTOR
a
ADDRES / CONNECTION'DATA
CIT �L NO 46� �&1 ' STATION _DEPTH 46
j
❑ STATE iMANHOLE REFERENCE PP
REGISTRATION NO ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO - TYPE ECTION LENGTH FROM
PUBLIC SEWER Q g 3 50 Y CURB P L At L TO P L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00 _
CONNECT ADDITIONAL BLDG OR P C NO
WOPK TO HOUSE SEWER 1 00 CO IMP NO / JOB NO `
ALTER OR REPAIR EXISTING '
SEWER OR DISPOSAL SYSTEM 1 00 'TRUNK PERMIT NO ROAD PERMIT NOmin
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 00 INDUSTRIAL ,
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
� � oo
OWNER'S PERMIT CONNECTION CHARGE FEE
_ -
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- ,
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
'� ,� 4 NEW HOUSE SEWER 2-2-0
SIGNED THIS DAY OF 19�-
OWNER 'OR !
CONNECT ADDITIONAL
OWNERS &GENT � �'" -� I f BUIEDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
•
ADDRESS L AND/OR DRAINFIELD '
1 HEREBY ACKNOWLEDGE THAT I HAVE RE THIS AP ICA CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT A AGREE TO C PLY
WITH ALL COUNTY ORDINANCES AND STA LAWS REGUL IN_G ALTER, REPAIR,SEWER OR _
PLUMBING AND SEWERS_- SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I 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 C �•
SEEP. PITS) ❑ CESSPOOLS 2-2/ O 1 41lS/J(fX1
SIGNATURE
OF PERMITTEE
J �
WILLIAM J. FOX.COUNTY ENGINCER VALIDATION R.A.WOOD. CHIEF PLBG.INSPECTOR-
4,
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