HomeMy Public PortalAbout4925 MCCLINTOCK AVE_Sewer__ 24650 INSER
`6A
76At;4PDS420g° APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
_ADDRESS. P -01�
WTOIiN A. T.AMBIE, County Engineer
I1111 T+�f A. IENSEN, Supt of Building LOCALITY
NEAREST ,t ,
FOR APPLICANT TO FILL JCROSS ST.
LEGAL
DESCRIPTION LOT N0. - 2 f ! OWNER �' __.- .�_,. .'-^. .- �... .._.�•?t
BLOCK TRACT - - MAIL
-'%.✓ _ ADDRESS e-^G•-'t ..>_..
NO.OF'BLDGS.
SIZE OF LOT � •� 'NOW ON LOT CITY TEL. N0,
USE OFxy DISTRICT NO. GROUP MAP P CESSED BY
UtLDiNGS ( r " i-�. zrK.... BK F6
CONTRACTOR _
ADDRESS "d, -g>�.. ,r' d- y CONNECTION DATA
CITY _. TEL.NO. g STATION , 'T 1 DEPTH n S
! STATE MANHOLE REFERENCE UPPER
REG'STRATION N0. � y �1 COUNTY Y� f! `"�
J � LOSYgit---
NO�--DESCRIPTION OF WORK FEE
HOUSES AER CONNECTING TO
PUBLIC SEWER (a $3..00 I �-Y.: TYPE OF CONNECTION - - LENGTH FROM -
SEPTIC TANK,SEEPAGE PIT OR I Y. CURB P.L. M.L.TO P.L.
PITS
AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXT N..CESSPOOL DRYNIELL cy $2.00
HOUSE SEWER CONNECTING TOI j P.C.NO:
l PR VAT- DISPOSAL SYSTEM { $1.00 t CO.IMP. NO. J K-`!_ JOB NO.
CONNECTO BLDG.0R TRUNK PERMIT NO. ROAD PERMIT NO. p
WORK TO HOUSEOUSE SEWER $P.00 �
ALTER,Rs rAROR ABANDON HOUSE �~ STATE ENCROACHMENT
SEWER OR DIS rOSAL SYSTEM
C $1.00 PERMIT NO p
INDUSTRIAL
--
WASTE APPROVAL P+i
CHARGES Vi
OWNERS PERMIT $ 2 00CONNECTION CHARGE FEE '
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- T
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY MJF 19e NEW HOUSE SEWER
OWNER ORJ/may CONNECT ADDITIONAL
OWNERS AGENTy BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
----- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE 7'0 COMPLY - CESSPOOL ❑ DRYWELL
WITH AI.L COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. .,ry ALTER REPAIR,SEWER OR
J SEWAGE.DISPOSAL SYSTEM
I HEREBY CERTIFY AT-' I AM PROPERLY REGISTER4D
ATE OF DISCONNECT PLUG AND
LICENSED AS REOiSiR �'Y LOS' ANGELES COUNTY AN STATE, OF ABANDON HOUSE SEWER
CALIFORNIA OR TH ; AM THE LEGAL NER OF THE ABOVE
DESCRIBED RESIDE AROPERTY. - BACKFILL SEPTIC TANKS ❑
P.,P4T(S) ❑ CESSPOOLS
SIGNATURE y 6✓''• �- -
OF PERMITTEE
dv t' VALIDATIO c-. ROBERT A. WOOD
C& 11..0. ✓CASH J SUPERVISING MECHANICAL, ENGINEER