HomeMy Public PortalAbout4939 MCCLINTOCK AVE_Sewer__ 6A642D61 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESS
UILDING
JOHN A, LAMBIE, County Engineer j a-�. ' c. l�
WILLIAM A. JENSEN, Supt of Building OCALITY f
EAREST -�
FOR APPLICANT TO FILL IN JtosS Sr.
LEGAL ` p
DESCRIPTION LOT NO ,r, Y� _OWNER �
BLOCK TRACT - rr MAIL
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ADDRESS �-�� -"
NO,OF B GS. r
SIZE OF LOT NOW ON LOT " CITY' I t TEL. NO.
USE OF _. —
BUILDINGS 0_ DISTRICT NO. GROUP_ MAP PROCESSED BY
CONTRACTOR ] l - E PG
ADDRESS t Vr l } CONNECTION/DATA
1 * STATION - - _ DEPTH
CITY TEL.NO...� ,° f y
REGISTRATION NO. COUNTY STATE MANHOLE REFERENCE /
NO. DESCRIPTION OF R FEE ' LOWER
HOUSE SEWER CONNECTING TO !
PUBLIC SEWER Q° $3.00 TYPE OF CONNECTION LENGTH FROM --
SEPTIC TANK,SEEPAGE PIT OR Y CURB P.L. M.L.70 P>Loy ,.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD ' d
E%TN,.CES5POOL.DRYWELL CA $2.00
HOUSE SEWER CONNECTING TO J /, P,C.NO. O
PRIVATE DISPOSAL SYSTEM @ $].00 CO.IMP.N0. JOB NO. U
CONNECT ADDITIONAL BLDG,OR
WORK TO HOUSE SEWER $1.00 TRUNK PERMIT NO. ROAD PERMIT N0. ®=
S8WER.OIE DISPO AL SYSTDEM HOUSE " 5].00 STATE ENCROACHMENT O
PERMIT NO, U
LU
INDUSTRIAL 13-
WASTE APPROVAL - N>
CHARGES z
OWNERS PERMS 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE AONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE CRISED EXISTINO DWELLING APPROVALS DATE INSPECTOR°SS1GyAT,URE
TO THE PUBLIC SEWER% F yr
SIGNED THIS DAI NEW HOUSE SEWER
OWNER OR : �.': s CONNECT ADDITIONAL
OWNERS AGENT 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 TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE.DISPOSAL SYSTEM
I HEREBY CERTtFY T -"I AM PROPERLY REGISTERED. AND/OR DISCONNECT PLUG AND
LICENSED AS REOU 9 LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR T T I M THELEGAL OVJ( ER OF E ABOVE BACKFILL SEPTIC TANKS
DESCRIBED REST TIA gtOPERTY.
SIGNATURE r `g SEEP.PITS Q CESSPOOLS13
OF PER-MITTS - -`�••
VALMATION- ROBERT A. WOOD
CIL, M.o. CASH SUPERVISING MECHANICAL.ENGINEER
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