HomeMy Public PortalAbout4915 MCCLINTOCK AVE_Sewer__ 24650 INSERT§ W
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78A&420 20�� APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER--SEWAGE-:DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADBRE N
1011N A. LAMBIE. County Engineer — r
ViiILLIAM A. JENSEN, Sup't of Building LOCALITY
NEAREST d�
FOR APPLI TO FILL IN CROSS ST.
LEGAL Z o f
DESCRIPTION LOT NO. •`, `_ 1I OWNER I BLOCK TRACT A �� l ADDRESSMAIL sd
NO.OF BL.DGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUI LDINGS DISTRICT NO.; GROUP MAP PROCES�BY
_ BK PG
CONTRACTOR
ADDRESS CONNECTION DATA -
CITY4
4Y w
TEL.NO' 6 STATION m �.1 DEPTH
�h
STATE MANHOLE REFERENCE
REGISTRATION N0. V e r f -COUNTY
NO. _ DESCRIPTION OF WORK FEE -- ---
HOUSE SEWER CONNECTING TO ¢p
PUBLIC SEWER CW $3.00 TYPE.OF CONNECTION -'N LENGTH FROM
SEPTIC TANK.SEEPAGE PIT OR Y. CURB P L. M.L.TO P.L. v. e
PITS AND/OR DRAINFIEt.D_
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN,.CESSPOOL. DRYWELi_ d $2.00
HOUSE SETA+ER CONNECTING TO P.C.NO. _
PRIVATE DISPOSAL SYSTEM P $1.00 CO. IM-P. NO. , JOB N0,
i CONNECT ADD;T?ONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT Na. O -
"VO 7z
TC HOU5E SEWER @ $1.00 _
ALTER R,PAIR OR ALANDON HOUSE I STATE ENCROACHMENT
SEWER:OR DISPOSAL SYSTEM @ $1.00 f PERMIT Na , p
INDUSTRIAL. -
WASTE APPROVAL twit
CHARGES U
OMMER"S PERMIT 00 CONNECTION C4A`ffG_E FEE
AUTHORIZATION I TOTAL FEE J 0 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH.THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. -- -
SIGNED THIS DAY OF 19— NEW HOUSE SEWER
OWNER OR ,.��.._
OWNERS AGENT �_� r_. -�- 4-� _ 'i-- .'S., CONNECT NGORDWORKAL
BL'I D.
ADDRESS - SEPTIC T'ANK.,SEEP.PIT(S)
AND/OR DRAINFIELD
LDREESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
TE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL (�
WITHLL. COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING APID SEWERS. SEWAGE DISPOSAL SYSTEM
EBY CERTIFY THAT I AM PROPERLY REGISTERED AND,!OR DISCONNECT PLUG AND
D AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AMIRE LEGAL OWNER OF THE ABOVE —ED RESIDEhiTIAi PR0'P RTY. a BACKFILL SEPTIC TANKSRE '" SEEP.PIT(S) (] CESSPOOL$ f_j
MITTEE -
7r
VALIDATIONROBERT A. WOOD
CK.�;' Y.0. CASH SUPERVISING MECHANICAL ENGINEER.