HomeMy Public PortalAbout4950 MCCLINTOCK AVE_Sewer__ 76AI42
3 1-6D6S%1.!55 APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE.COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS Sr.
LEGAL
DESCRIPrION LOT NOOWNER
MAIL
BLOCK TRACT
_SS
4
NO.OF BLDGS. fk '
SIZE,OF NOW ON LOT CITY
1:1A TEL. NO.
USE OF
JUILDINGSDISTRICT N0.O. GROUP MAP
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA*
STATION Iio' DEPTH
CITY TEL. NO.
MANHOLE REFERENCE U_PPEfi_
STATE
REGISTRATION NO. ❑
COUNTY
NO. DESCRIPTION OF WORK FEE
TYPE:OF' CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TOY.
PUBLIC SEWER @ $ 1.501 CURB L. M.L. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR 0(j,
_4
PITS AND/OR DRAINFIELD 3.00
—- — - iELD I - Njr
WVIERF;�OW SEEPAGE PAI-M —
EXTN.,CESSPOOL,DRYWELL.f-.1 AN HOLE $2.00 1 CO, IMP. NO, z,:w- JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.Or I STATE, ENCROACHMENT
JWORK TO HOUSE SEWER (,,I $1:00PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT 1 00
- — 1� REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE 4- 1tC.",
I HAVE AT THIS DATE. A CONTRACT WITH 'THE HEREIN NAMED CON- _APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING,
TO II-T.E PUBLIC SEWER. SEWER
NEW HOUSE
SIGNED THIS-
-------;_—DAY OF_____I9__ CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT__----------— SEPTIC TANK,SEEP,PITS)
RDDR_cSS: AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _C_ESSPOOL L] DRYWELL Ll
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL. OWNER OF THE ABOVE ABANDON-HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS C_j
SIGNATURE SEEP.PIT(S) [j
OF PERMITTEE
1OHN A. LAmE31E. COUNTY ENGINEER VALIDATION-—-.,,ROBERT A. WOOD, CHIEF PL8G. 11"45PECToR
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