HomeMy Public PortalAbout5035-5037 MCCLINTOCK AVE_Sewer__ reA°4z°
19.5$ APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
AESS
JOHN A. LAMBIE, COUNTY ENGINEER DDR —.__—
?i CASSATT D. GRIFFIN, SUPT OF DU(LUING LOCALITY
FOR APPLICANT TO FILL IN doss ST. F
LEGAL ,
DESCRIPTION LOT NO. ....OWNER
BLOCK TRACT /.;,i £'-/` MAILADDRESS —
N0. OF BLDGS. w CITY TEL. NO.
SIZE OF LOT NOW ON LOT _ -'
USE OF fr a
/ DISTRICT NO. GROUP MAP
BUILDINGS y -'.. :e -.— _ 11 y,.r
BK PG
CONTRACTOR"
CON fdN_ DATA
ADDRESS '`__ .r-. " +: a ----- -- ---------- ----- ---- -----
_ _STATION + DEPTH j y _
CITY , TEL. N0. --- rte— — - - — -.
MANHOLE REFERENCE
[] STATE ------ .-`. _ LO1r'ER
REGISTRATION NO. [] COUNTY
NO. j DESCRIPTION Of WORK FEE - -• ---- - -
1 HOUSE SEWER CONNEGTING TO TYPE OF CONNECT LENGTH FROM
PUBLIC SEWER -Y-.----CURB u.L. M L. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR l E
PITS AND/OR DRAINFIELD kZ $3.00 ---- -
--- .-- --- --..._ P r N 0.
_1 OVERFLOW SEEPAGE PIT, DRAt NFIELD
EXTN.,.CESSPOOL,DRYW_E_L_L,MANHOLE C $Z.00 j _CO. IMP NO. — JOB NO.
I HOUSE SEWER CONNECTING TO
— ---- - --
PRIVATE DISPOSAL SYSTEM a $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR i- STATE ENCROACHMENT
i._I. WORK TO HOUSE SEWER_ _ n $1.00 i �'_� PERM(T N0. ---.^.— ___.-_--- -_._...------ _----__ -.
I ALTER,REPAIR OR ABANDON HOUSE J INDUSTRIAL
-_-�- SEWER OR DISPOSAL SYSTEM r .$1..00 I WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT � _ t oo ----- -------------- —_—_ —
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE s" ---
I HAVE AT THIS DATE A CONTRACT WITH 'THE HEREIN NAMED CON APPROVALS I DATE f INSPFC'TOR 53IGN PTURE..
TRACTOR TO. CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC, SEWER. NEW HOUSE.SEWER
SIGNED THlS DAYf 19
_ ------
CONNECT ADD[T OtdAL
OWNER OR. / �� t-- s , -.- BUILDING OR WOPK
OWNERS AGENT e • .,�"'? J �,, L,�- 1�., r ,p.; .i� --- —
SEPTIC TANK SEEP PTT;S) :F1
~�
ADDRESS— —4 .—� AND/OR DRAINFiELO I --- �..-------.. ----
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOLL] DRYWELLO
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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 DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER -
CALIFORNIA OR THAT i AM. THE LEGAL OWNER OF THE ABOVE -------------- �— -I--------- --
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS[I
SIGNATURE ,
SEEP.PIT(S) [; CESSPOOLS❑�_
OF PERMITTEE �..'r•'
i
i
10HN A.LAMBIE,COUNTY ENGINEER VALIDATIO] ROBER1 A. WOOD, CHIEF PLBG. INSPECTOR
CK, td.D. GASH -
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