HomeMy Public PortalAbout6632 CLOVERLY AVE_Sewer__ 20
S&E.16 9 11-55 A P PU C A TMll V FOR W U P E 61 Y 1]1911�T
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL"
Department of County Engineer
County of Los'Angeles N BUILDING -"
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT of BUILDING <+ LOCALITY
.•. A STT T
NEAREST
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O F r CROSS ST.
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DESCRIPTION LOT N0, ' '�� ^�' OWNER Ap
BLOCK' T 0, ADDR
" ESS ��_�,. (,%��lYA�e�f
y eye NO. OF BLDGS. / CITY TEL N0.
SIZE OF LOT 6:5r i.J•§_ NOW ON LOT USE OF ` DISTRICTNO.. GROUP - MAP
'BUILDINGS - - q ' BKA PG
CONTRACTOR � '
q
ADDRESS �/ CONNECTION DATA
�-� � � •.
STATION
_ DEPTH
CITY / TEL. NOMANHOLE REFERENCE p .
P
❑ STATE7
REGISTRATION N0. / � �i COUNTY
- '
NO. DESCRIPTION OF'WORK FEE
TYPE OF CONNECTIONLENGTH FROM D
HOUSE SEWER CONNECTING TO -yy - � P•L` - M.L.TO
PUBLIC SEWER. @ $3.50 •• 'V T
r SEPTIC TANK,SEEPAGE PIT OR - -
PITS AND/OR DRAINFIELD c@ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD _ P.C. NO. ,
EXTN.,CESSPOOL,DRYWELL,MANHOLE Coil $ 2.00 CO. IMP. NO. 'OB NO. -
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM . '1 ,$1:00 D TRU N PERMIT NO. - ROAD P T NO,
CONNECT ADDITIONAL BLDG.OR STATE A
E CHMENT -
WORK TO HOUSE SEWER - @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM tt $1.00 WASTE APPROVAL.
a -CHARGES
1
CONNECT! CHARGE-FEE' -
OWNER'S PERMIT S 1 00 ? '
REIMBURSEMENT FEE - -
AUTHORIZATION TOTAL FEE Sp
` 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSP.E CTO R'S SIGNATURE,
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING — - .R �
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF- 19 CONNECT ADDITIONAL
OWNER OR .- BUILDING OR WORK
OWNERS. AGENT - //lsssll t/���/// -
,. SEPTIC TANK,SEEP, PIT(S) .
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1HAVE READ THIS APPLICATION CESSPOOL❑ DRYW ELL❑
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
I 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 1 AM THE LEGAL OWNER OF THE ABOVE -
DESCRIBED RESIDENT L PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE ,�SEEP. PIT(S) ❑'CESSPOOLS -2,4-s 9,
�'- -
OF PERMITTEE -
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION---t) ROBERT A. WOOD, CHIEF.PLBG. INSPECTOR
CK Id.0. �r/CASSHH / -