HomeMy Public PortalAbout6643 CLOVERLY AVE_Sewer__ 5&E-663 11.55 fi"11 P P U C A II MIJV FOR 41 E R M !1
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL cn
Department of County Engineer "" A
County of LOS Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN. SUPT OF BUILDING y; LOCALITY
NEAREST.
FOR APPLIC NT TO FILLR IN CROSS STp
12
LEGALO OWNER
DESCRIPTION LOT NO.
MAIL
BLOCK TRAG ADDRESS
N0. CITY TEL. N0.OF BL GS.
SIZE OF LOT NOW ON LOT ! -
* USE OF - DISTRICT NO. GROUP - - MAP
BUILDINGS
PG
CONTRACTOR c
CONNECTION DATA 1
ADDRESS
STATION DEPTH
`- CITY _ TEL. NO. ® - - PPE .
' MANHOLE REFERENCE A
` Ov
STATE
REG ISTRAT 10 N0. / -2 �� COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CON ECTIO LENGTH FROM G
(# - P.L• M.L.TO P.L.
PUBLIC SEWER @ $3.50 3 5� _
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C..NO.
EXTN.,CESSPOOL,DRYWELL,MANHOLE n $2.00 CO. IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO '
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. - ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR , STATE ENCROACHMENT
WORK TO HOUSE SEWER c_i $1.00 PERMIT NO,
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL -
SEWER OR DISPOSAL.SYSTEM n $1.00 WASTE APPROVAL '
RGES
CONNECTION CHARG E
OWNER'S PERMIT $ 1 00
AUTHORIZATION I TOTAL FEE �, .5-,0REIMBURSEME •tF�EE
"
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- A O tl AI'S DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.. NEW HOUSE SEWER -
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR P4.
/fir BUILDING OR WORK _
OWNERS AGENT-1 � �� & 0• p�^Aa - —��� SEPTIC TANK,SEEP, PIT(S)
ADDRESS - - - .AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[] DRYWELL❑ '
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 I AM THE. LEGAL OWNER OF THE ABOVE _
DESCRIBED RESIDEN"LPROPERTY. BACKFILL SEPTIC TANKS❑ r1
SIGNATURE
SEEP. PIT(S) Ll CESSPOOLS T
e OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
•� CK. N.0. ASH