HomeMy Public PortalAbout5010 MCCLINTOCK AVE_Sewer__ 24650 INSERTS
7CA66.60
7eAs42D APPLICATION FOR PERMIT:.._. -
COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOI3N A. LAMBIE. County Enggineer ADDRESS
WILLIAM A. JENSEN. Sup't of Building F
LOCALITY �•� .� -
NEAREST
FOR APPLICANT TO FILL. IN cRass sr.
r
LEGALa a
DESCRIPTION LOT NO. ( �i � _ - ,OWNER-�9 „ :,;��i�k s`,.- �` 1-1,"f
BLOCK TRACT a:
� r ,/ ADDRESSY'`Ii
a - N0.aF BLDGS_
SIZE°OF LOT / NOW ON LOT, CITY r - r TEL.
USE:.OF' �� 7
6 U I L D I N GS;;:.�" ;K' " DISTRACT N0. GROUP,f $K MAP P� PROCESSED BY
_CONTRACTOR 2`
ADDRESS ` � / :. s CONNECTION DATA
CITY . TEL.NO. STATION DEPTH
TA'tE MANHOLE REFERENCE UPPER
REGISTRATION N0. COUNTY
NO. DESCR!!'I ON OF-WORK FEE
HOUSE SEWER CONNECTING TO —�
__f�UPIJC SEWER _ C? $3,00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P*L*
PITS ANDIOR DRA;NFIELD @ $9.00 —^-
OVERFLOW SEEPAGE PIT.DRAINFIELD `.-..
tX.N.. C_5SPO0l. DRl'WELI $2.00' _
rHOUSE S CRIER CONNECTING TO _ P.C.NO.
�I PR,'uATE - IS_OSA.L SYSTEM is S1.p0 CO,PMP. N0. _ JOB N0.
r 'RK TO KDSE fAt-BLDG,OR 0
WORK TO HOUSESEWER $1.00 TRUNK PERMIT N0. ROAD PERMIT NO. O
A T 'R, h PAIR OR APANDON HOUSELT
SwNFR O D,'SPOSAL SYSTEM @ 59.00 STATE ENCROACHMENT
PERMIT NO. O
INDUSTRIAL U
- - WASTE APPROVAL 2
6>+
_ CHARGES
OWNER'S PERMIT $ I 2 00` CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE � REIMBURSEMENT FEE
I HAVE AT THS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE dNSPECTOR.'S SIGNATURE.
TO THE PUBLIC/ -,- _. ------
SIGNED THIS'-_-QDAY OF 191—" NEW HOUSE SEWER
OWNER OR -r CONNECT ADDITIONAL
OWfN'LRS AGENT. w_?' 4"..r - _ BUILDING OR WORK
ADDRESS �L - -- =-`' ` > - 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 ❑ DRYW£LL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANDJOR SEWAGE
N DIS PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OE DISCONNECT
ISCO N CT PL SEWER
CALIFORNIA OR THAT 1 A14 THE LEGAL OWNER OF THE ABOVE ABAN--
DESCRIBED RESIDENTIAL PROPERTY BACKFILL.SEPTIC TANKS
SEEP. PITS) 0 CESSPOOLS Q
SIGNATURE r` G �— —
OF PERMITTEE
1
�F
VALIDATION— ROBERT A. WOOD
CK. U.0. CASH SUPERVISING MECHANICAL, ENGINEER
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