HomeMy Public PortalAbout4928 MCCLINTOCK AVE_Sewer__ E-C$3 Z-515 APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Lor Angeles BUILBUILDING ` j ';
WM.J. FOX,COUNTY ENGINEER
CASSATT D.GRIFFIN,SUPT OF SU1LOING4 _--
LOCALITY
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FOR APPLICANT TO FILL IN —NEAREST � s
cRass sr.
~ LEGAL —T - — -
DESCRIPTION LOT N0. `' � _ OWNER t fj_
BLOCK TRACT ! .r MAIL ,A: ,,.- y9 'Z`'i�"'� :°..,-_
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NO. OF'iLDGSADDRESS ,yp, z�d
SIZE OF LOTY' �': ,� u NOW ON LOT CITY TEL. N0,
USE OF
6UiLDIN GS µ ms` DISTRICT NO. GROUP MAP
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CONTRACTOR[ F''
ADDRESS a '- ,.� --._ CONNECTION DATA
CIT - TEL. N1) 1` ...,' STATION _ DEPTH
' [ STATE MANHOLE REFERENCE
REGISTRATION NO COUNTY
y, Q COUNTY
NO. DESCRIPTION OF WORK FEE _
-- t �X I .. TYPE OF CONNEC'FIL'P M, 1.LENGTH R01�.—
HOUSE SEWER CONNECTING TO � $
Y. CURB P.L.'' M1 t..TO P L '
PUBLICSESiER3-SO
HOUSE SEWFR CONNECTING TO -
__ PRIVATE_DiSPOSAL SYSTEM 1.00
COYNEC7 ADDITIONAL BLDG.OR - P. C. NO. -
WORK TO HOUSE SEWER 1.00 j t, ? _CO. IH°. NO ;,� _JOB NO.
-ALTER OR REPAIR EXISTING
EWER OR DISPOSAL SYSTEM 9A0 TRUNK PERMIT NO. ROAD PERMIT NO._
DISCONNECT AND ABANDON SEWER + STATE ENCROACHMENT
_
AND/OR DISPOSALSYSTEM _ _ 1,00 PERMIT NO
_� SEP-TIC TANK SEEPAGE PIT OR _ --
PITS A_YDCR_DRA I N FIELD .QO�. INDUSTRIAL
CESSPOOL DRYWELL WAST:APPROVAL
SPECIAL CONDITIONS ONLY 2.06 CHARGES
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�—
CONNECTION CHARGE F E ---- — - '�
OWNER'S PERMIT �— t� 00 — -- -- -- �J — ------
AUTHORIZATION TOTAL FEE ' s � � REIMBURSEMENT ) C.
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NJED J CON�' ys,�o
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING. APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS _DAY OF NEW HOUSE SEWER ----
'" -
OWNER OR CONNECT ADDITIONAL 1
11
OWNERS AG£NT� - _..T-... .—..—._..— _ BUILDING OR WORK - — -
SEPTIC TANK, SEEP, PIT(S)
ADDRES5. _ _ _ _ __ A-ID/0R_D RAINFIELD
I HCRrBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL.0 DRYWE.LL 0_.--
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 _
1 HEREBY CERTIFY THAT I Ali PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY 1.05 ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE S.EWLR _
.DESCRIBED RESIDENTIPROPERTY. BACKFILL SEPTIC TANKS G
SEEP. PIT(5) 0 CESSPOOLS'Q _
SIGNATURE
OF PERMITTEE <-
WILLIAM J. F X.COUNTY ENGINEER VALIDATION R.A.WOOD.CHIEF PLOG. INSPECTOR