HomeMy Public PortalAbout5028 MCCLINTOCK AVE_Sewer__ DEPMUMENT OF COUNTY ENGINEER SEWER--SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS .ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICA1T TO .; lLL IN LOCALITY
BUILDING NEAREST
ADDRESS CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
--NEAREST _._ __� --- —c--/-- A I J
c
CROSS ST. f I
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL ! USE ZONE OCCUPANCY j MAP
ADDRESS '��� I BK PG
CITY TEL.1140.4 ---
--
CONTRACTOR
CO.IMP.NO.
ADDRESS
JOB NO,
CITY T�Y TEL TRUNK PERMIT N0.
TE
REGISTRATION NO �` COUNTY ROAD PERMIT NO
LEGAL ,l STATE ENCROACHMENT
DESCRIPTIO kfl-F'ND
---� , PERMIT N0.
BLOCK TRACT r, - INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS. .. CHARGES
NOW ON LOT
USE OF
BUILDINGS j`- CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK: FEE —� --
REIMBURSEMENT FEE.
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 3.50 RECEIPT NO. DATE IBY
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 NO. I DATE IBY
SEWER OR DISPOSAL SYSTEM 1.00_
DISCONNECT AND ABANDON SEWER
_AND/OR DISPOSAL SYSTEM I.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
--PITS AND/OR DRAINFIELD 2.00STATIONDEPTH
p '
CESSPOOL—DRYWELL '
SPECIAL CONDITIONS ONLY 2.00f MANHOLE REFERENCE �WEo
� I
TYPE OF CONNECTIONLENGTH FROM
OWNERS PERMIT $ I , 00 , Y. CURB P.L. .r" M.L.To P.L. _3 ✓
�,.
AUTHORIZATION I TOTAL rEE -"
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'SSIGNATURE DATE
DWELLING TO THE:PUBLIC SEWER
SIGNED THIS__-. _.D _OF-. t ._•..i9_ _ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL I
OWNERS AGENT v BUILDING OR WORK
,. ,}}f SEPTIC TANK,SEEP.PIT(S)
ADDRE$$", lk'� •--- ' I d - :. ------.. -•- ..-.le,�_.- AND/OR DRAINFIELD I
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL 0 DRYWELL 0
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, SEWAGEDISPOSAL SYSTEM
_DISCONNECT PLUG AND
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
USE SEWER
ER OF THE ABOVE DESCWED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
j SEEP.PIT(S)o CESSPOOLS 0
SIGNATURE
IG PERMITTEE... ....... ..._.._. :. .. ' T
76A642A 663 7/53 �� 4-