HomeMy Public PortalAbout5113 MCCLINTOCK AVE_Sewer__ w.
'BA,6fZo-cEaOB.-1°-'' APPLICATION FOR- PERMIT
COUNTY OF LOS ANGELES SEWERSgWAGEDJSPOSAL .
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS \_• 1
LOCALITY
NEAREST
FOR APPLICANT TO FILL: IN aRDse sr.:
LEGAL �[
DESCRIPTION LOT NO. OWNER `
MAIL
BLOCK _ TRACT tf ADDRESS Im 'i
NO_ OF BLDGB, r -
SIZE OF LOT NOW ON LOT CITY .{ ^_TEL. NO.
USE OF
BU ILD.INGS DISTR.ICTNO.. GROUP MAP OCESSEO BY
BK PG
CONTRACTOR01-if 19 1 Cie
, d2a��
y
ADDRESS / CONNECTIONDATA
CITY TEL. NO. STATION .DEPTH
STATE 'LIC 16
NHOLE REFERENCE UPPER
L-(CENSE ]NO, CL A'SS _ LOWER.
NO. .DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE:SEWER CONNECTING TO 'Y.. CURB :P.L. M.L.TO.P.L.
PUBLIC SEWER. @ .$7.00' P.C.NO.
.
SEPTIC TANK:SEEPAGE PIT OR CO.IMPNO., JOB NO.
PITS AND/OR DRAINFIELD ! 310.00 _
HOUSE SEWER CONNECTING.TO d
PRIVATE bISPOSA'L SYSTEM Q 38.00 TRUNK PERMIT NO. ROAD PER O.
CONNECT ADDITIONAL11AFFIDAVIT WAIVER "6A5[MCM7 RECORD:.INSTRw NO. DATE O
WORK TO HOUSE.SEWER ® f 9.00 V
OVERFLOW SEEPAGE PIT.DRAINFIELD ..
E:XTN..CESSPOOL,ORY W ELL. 53.00
ALTER.REPAIR'ORABANDON HOUSE HWY.OR ST.WIDENING 0
SEWER OR DISPOSAL SYSTEM f8.00 STATE ENCROACH'MEN W
MANHOLE a $7.00 PERMIT NO.
INDUSTRIAL �a
WASTE'APPROVAL d rNzk
k
CHARGES
OWNERS PERMIT s 3 o°.
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.. REIMBURSEMENT FEE
TRACTOR TO CONNECT WE ABOVE DE RIBED EXISTING DWELLING
TO THE PUBLIC SE _ APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED TH AY O 1'9��
OWNER OR NEW HOUSE SEWER d
OWNERS AGEKI AMA ` CONNECT ADDITIONAL
ADDRESS C 1V T BUILDING OR WORK
1 HEREBY ACKNOWLEDGE. THAT 1 HAVE READ THISSEPTICTANK.SEEP.PIT(S).APPLICATION AND/OR DRAINFIELD'
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1. HERESY CERTIFY THAT 1 .AM PROPERLY REGISTERED AND/OR ALTER;REPA.IR..SEWER OR
LIENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
.CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. T 60VE DESCRIB RESIDENTI L PROPERTY.. ABANDON HOUSE SEWER
SIGNATURE: BAGKF.ILL SEPTIC TANKS ❑
OF PERMITTEE_ .SEEP:PIT(S) ❑ CESSPOOLS ❑
VALIDATION CK. M.D. CASH „
r
A
DEPAW--UMENT OF COUNTY ENGINEER SEWER SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER ADDRES G
ADDRESS -------------
FOR APPL1 NIT FILL I LOCALITY
BUILDING - y� NEAREST
, i
ADDRESS;� ` '�... r .'�' L.-�y. mss' CROSS ST,
LOCALITY __y_ F...�:_ :_ DISTRICT NO. SERIAL N0. PERMIT N0. .
NEAREST A
CROSS ST. t RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL
ADDRESS` USE ZONE OCCUPANCY MAP
- -� BK PG
CITY'
—�'=.�..fc2i; TEQQN
CONTRACT" CO.IMP.N0.
C —- —
ADDRES J F !OB NO. ------
TEL.N�2L, TRUNK PERMIT N0. -
REGISTRATION NO. yt COUNTY ROAD PERMIT N0. =•y- �"
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. yr - _PERMIT N0.
BLOCK TRACT �3' a INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO OF 6LQGS. CHARGES
ROW ON LOT
USE OF
i
BUILDINGS -T-y ° �_3 CONNECTIO-1CHARGE FEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT
HOUSE SEWER CONNECTING TO
PUBLIC_SEWER @ $ 3.50 '' RECEIPT NO. I $TE` (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 BY
SEWER OR DISPOSAL SYSTEM _ 1.00
DISCONNECT AND'ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA '
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRY W ELL ------- —
SPECIAL CONDITIONS ONLY 2.00 MAi*io:_.!:REFERENCE
t' UPPER: LtL"a
TYPE OF CONNECTION`"~ NGTH FROM
OWNERS PERMIT $ I oo
Y. CURB P.L. M.L.TO P.L.
r ; - –
AUTHORIZATION TOTAL FEE -
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS..... _ -------DAY OF;f. 1(n; {°. --.14 NEw HdusE SEWER
OWNER OR g CONNECT ADDITIONAL
OWNERS AG& .y�°LGk1. L;e.........
BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
AND/OP.DRAINFIELD
CAITHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELL E
ION 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 _
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
s
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE,DEWRIBED RESIDENTIAL PROPERTYBACKFILL SEPTIC TANKS
'�. v SEEP.PIT(S)E] CESSPOOLS
SIGNATURES y �
OF PERMITTE .._ -.._.._..L
..•••..
76A642A 663 7/53