HomeMy Public PortalAbout4921 MCCLINTOCK AVE_Sewer__ :E808 10-63
SAC420 APPLICATION FOR PERMIT
COUILTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 9 ILDING
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JOHN A., LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building _0�A L"y
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1- CALXTY
N AF�FST
CROSS ST.
FOR APPLICANT TO FILL IN
D ESc R_1P:T_10N LOT NO. 'p, 7 OWNER
M-A I L
BLOCK TRACT 'y - ------ ADD P E,S
NO. OF 8 LD G S.
SIZE OF LOT NOW ON LOT C,I TY TEL, NO,
USE
BUILDINGS DISTRICT NO, GROUP MAP P OCESSED BY
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CONTRACTOR
ADDRESS, CONNECTION DATA
CIT}' TEL. N 0 STATION DEPTH
✓camR-STATE, MANHOLF,REFERENCE
REG[STRAIION NO. COUNTY LOWER
NO, U E S R I PT 10 NO F�)A R K FEE TYPE:OF_cOt_4_NECTION,7_�_ _ LENGTH"RCM
HOUSE_iWER CONNECTING TO CURB �i P L.- 14.L.TO P.L. -J,
pull C -57 P.C.NO.
S'E Ae, Y
EWER @ 5 5,0-1
NO. JOB NO.
___L�F P�T I C_NT iEEPA G PIT OR Co.IMP�
P�
DA:
DRAINFIELO @ $;10.00 6-
HOUSE SEWER CONNECT �TO TRUNK PERMIT NO- ROAD PERMIT NO.
PR VATS DISPOSAL SYSTEM $3.00
C'7NNECT ADDITIONAL,BLDG.OR FIDAVITWAIVER IASZMEqT RECORD.INSIR.NO. DATE
WORK TO HOUSE.SEWER @ S-1.0o
0-11ERGEPIT
FCOW SEEPA ,ORAiNFIEL [ LU
EXTN.,CESS POOL,QRY WELL,MA NHOLF $5.00
HOUSE —t— HWY,OR ST.WIDENING
ALrr.R, REPAIR OR ABA NDbN z
OR DISPOSAL SYSTEM @ $3,00 _—EN -CROA -CHMIENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
O _ER"S ECHARGES.1-
WNRMIT $ ;2 00
CONNEC'T ION CHARGE FEE
AUTHORIZATION
HAVEAY
THIS DATE A CONTRACT WITH THE HERV!N NAMED CON- REIMBURSEMENT=
TRA CTO R T 0 CON SCONNECT THE. ABOVE DESCRIBED CX!STIN G DWELLING
TO THE 'VBLIC EWER, APPROVALS INSPECTOR'S SIGNATURE
F
SIGNED THIS--DAY
OWNER OR NEW HOUSE SEWER
CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK,SEEP,PiT(S)
HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFtrLE)
AND STATE E ABOVE IS CORRECT AND AGREE, TO CQMFIL.Y
W S
WITH
THAT THE
ALL COUNTY ORDINANCE AND STATE LAWS REGULATING
PLUMBING AND SEWER . CESSPOOL [I LRYWELL F-
I HERESY CERTIFY THAT IAM PROPERLY REGISTERED AND/OR ALTER. REPAIR,SEWER OR
*I CENSID AS REQUIRED BY LOS AND STATE Or SEWAGE DISPOSAL SYSTEM
ANGLES COUN
*ALIFORN I A OR THAT I AM T H E LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. rHE (,;"'BED
"'BED !RESIDENTIAL P ROPEjfty. ABANDON.HOUSE SEWER
SIGNATURE UE�
ABSA"'r
OF PE
EE
BACK r'IL S
L EIT I C TAN111
11E1,11:1'IS CESSPOOLS, ot
VALIDATION ROBERT A. WOOD
f SUPERVISING MECHANICAL ENGINEER
CK M.O. CASH
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