HomeMy Public PortalAbout5011 MCCLINTOCK AVE_Sewer__ DEPA.RTbIENT OF COUNTY ENGINEER -- :+ SEWER-,SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY `, PERMIT APPLICATION .
COUNTY OF LOS ANGELE8 '
WILLIAM J. FOX, COUNTY ENGINEER BUILDING' / /
ADDRESS ,� `/ ��, f CZ ! �ZBUILD
FOR APPLI NTT LL I LOCALITY r .�g,, /p�
NEAEST
ADDREST :. CROSSST.. /N AO M1/—
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO. C
NEAREST e� A �V �✓ J
GROSS ST..
RECEIVED BY Randy for Inspection /,,DA7IS�S��
OWNERle
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MAIL US ON OCCUPANCY MAP
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CONTRACT �`
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ADDRESS JOB.N0.
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CI TEL ` TRUNK PERMIT NM
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REGISTRATION N0.- COUNTY ROAD PERMIT NO.
LEGAL r• STATE ENCROACHMENT
DESCRIP NO is PERMIT NO.
BLOCK /TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OFF BLDGS. CHARGES
Nol ON LOT
,!USE OF ONNEC7'ION GE FEE
=BUILDINGS
?.NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER G $ 8.50 RECEIPT NO. D BY'
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG:OR _ EXCEPTION RECORDED
WORK TO.HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING N0. I DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND-ABANDON SEWER
AND/OR DISPOSAL SYSTEM I.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR g
PITS AND/OR DRAINFIELD 2.00 ' STATIC ,3 C? :DEPTH
CESSPOOL.=DRYWELL
/// SPECIAL CONDITIONS ONLY 2:00 ANHOLE REFERENCE
LOWER
TYPE OF CONNECTION ENGTH FROM /
OWNERS
PERMIT ; I Y. CURB P.L'. M.L.TO P.L. Z Q
AUTHORIZATION TOTAL FEE .�
COIS DATE CONTRACTED WITH THE HEREIN R TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS
NTRACTOINSPECTOR'S-SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER_ � - _
SIGNED THIS. � _D NEW HOUSE SEWER �_�1n LA's�
OWNER OR BUILDING OR CONNECT ADDITIONAL
OWNERS ArtENT _ WORK
�:' SEPTIC TANK,SEEP.PIT(S) '
ADORES AND/OR DRAINFIEL•D
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPL'1- 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 DISCONNECT PLUG AND
1 HEREBY CERTIFY THAT 1 •AM PROPERLY REGISTERED.
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE-SEWER
AND
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE AWVEDCRIBED SIDENTIAL ROPERTY. BACKFILL SEPTIC'TANKS❑ tSIGNATURE ' SEEP.PIT(S)E] CESSPOOLSO V
OFPERMITT.E ._.._.._... .........
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