HomeMy Public PortalAbout4947 MCCLINTOCK AVE_Sewer__ D�� r OF cOUNW SvaITEEIS SEWER—SEWAGE :DISPOSAL 1
DIVISION OF BUILDING AND SAFETY
comvzY of a os PERMIT APPLICATION
O
WILLIAM J. FX, COUNTY ENBINEERBUILDING //C A
ADDRESS
FOR APPLICANT TO FILL IN n
LOCALITY
BUILDING
UILDS S-44 //+�'L�.�/f/Ct 6 C C AUf CRDSSST.
ADDRESS �I�// i ��++ / C
LOCALITY �P Ce 7Y DISTRICT N0. Ready for Inspeo4ion PERMITAO.
NEAREST ,.4 S
CROSS ST.�.�J s i J
//' / / Dt,ATE I U D BY DATE
OWNER i��•�V " � T llU".+�, �"�yy 1yK� //,DATE ����
ADDRE$S.op 7 GgI: zdLe'zz&- USE ZONE OCCUPANCY BK MAP PO
CIT jaSt_T-ELNO.eaojZe
-4- I
CONTRACTOR
CO.IMP.N0. fi)
ADDRESS
JOB NO.
CITY TELAO. TRUNK PERMIT NO.
STATE
REGISTRATION N0. COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT N0. A Q� STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT a INDUSTRIAL
SIZE OF LOWASTE APPROVAL
.T �y� t N0.OF SLOGS. �t
�/�/ 3 J NOW ON LOT ( CHAR48/
USE OF • i-•,
BUILDINGS e i j�J/ �y y 0.4 CONNECTION CHARGE FEEA.
NO. DESCRIPTION OF WORK FEE
THOUSE SEWER CONNECTING TO' REIMBURSEMENT FEE
PUBLIC SEWER 0 ;. 8.50 RECEIPT NO. I DATE I BY'
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM •1.00
CONNECT ADDITIONAL BLDG.OR CEPTION RECORDS
WORK TO HOUSE SEWER 1.00
ALTER O.R REPAIR EXISTING N I DATE BY
SEWER OR DISPOSAL SYSTEM A.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK.SEEPAGE PIT OR
PITS.AND/ORDRAINFIELD 2.00 STATION �'� DEPTH
CESSPOOL—DRYWELL .4 4 '.
SPECIALCONDITIONSONLY 2.00 ,{ � REFERENCE
MANHOLE.R
eL / UPPE
TYPE OF CONNECTION LENGTH.FROM O
OWNERS PERMIT $ .I 00 'GUl4IB" P.L. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE 1$'
1HAVE THIS DATE CONTRACTED WITH THE. HEREIN..NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER +-
SIGNED THIS DAY OFA 19__ -NEW HOUSE SEWER ,eit,
OWNER OR CONNECT'ADDITIONAL
OWNERS AGENT_._____ BUILDING OR WORK
AND/OR DRAINFIELD PIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL[] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR.SEWER OR
REGULATING'PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR.LICENSED AS REQUIRED BY LOS ANGELES COUNTY
AND STATE OF CALIFORNIA OR THAT 1 AMT E/BEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABO DESCRIBED ESIDEN P OPERTY.. BACKFILL SEPTIC TANKS
SEEP.PIT(S)[] CESSPOOLS
SOF PERMITTEE_ !.._cF'•� _ _.�._._..�_... � ! ;i!/�I'� �`� i .
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