HomeMy Public PortalAbout5124 MCCLINTOCK AVE_Sewer__ t'S`(k Z-669 72.51 APPLICATION FOR PERMIT
DIVISIION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Eepsrlanent of County Engineer
County of Los Angeles BUILDING
WIM. J. FOX, COUNTY ENGINEER ADDRESS
CASSATT 0. GRIF=FIN.SUPT O 13UILDIN� LOCALITY
F APPLICANT TO FILL IN NEARESTp•- s �
. `�- - -- - -
CROSS ST.
LEGAL .,.v J ,4~ ��_ -•- - J.. -_
DESCR1PTi0N _LOT NO, OWNER � ., ✓„ ,4 ;�
BLOCK �� TRACT :c.4 1�AIL
ADDRESS
- NO. OF BLDGS. .v
S;Zf OF LOT NOW ON LOT
CITY - TEL. NO,
USE OF ,,,,�
BUILDINGS id a°' -
DISTRICT NO. � GROUP I MAP
CONTRACTOR S Z, K PG -
ADDRESS ,y CONNECTION DATA
CITY t - NO. F�+ ,,+ STATtON { DEPTH
STATE y MANHOLE REFERENCE �-
REGISTRATION NO. COUNTY
TYPE OF CONfJEy^T =_- LENCTH FROM —
N0. DESCRIPTION OF WORK EEE _ CURB P.L. . M.L.TO P.L.
HOUSE SEWER CONNE TING TO
PUBL!C SEWER - C $ 3.40 --- --
----- —
HOUSE SEWER CONINEC.TING TO
PPIJA'L DISPOSAL SYSTEMCONNECT ADDITIONAL ADDI IONAL LLDG, OR
WORK TO HOUSE StV_EP 30 I CO. IMP. N0, ff�"`'• wOB. NO,
�I AL'fEI?OR REPAIP EXISTING
_ ScWER 03 D-ISPO_SAL SYSTEMLOO !� TRUNK PERMIT NO. ROAD PERMIT NO. --
D CONNrt AND ABANDON SEWER
ANDqR I'.SPQSAL SYSTEM !.00
STATE ENCROACikENT
5E?f1C TANK SEi.PACE PIT OR � - -
PITS AWL O4 DRAINF ELD 2.G j INDUSTRIAL
i Cl'�5P,3v1 DRYJ�ELL
". �.` _-- `JA IE APPROVAL
SP iAL CUP I CTONS ONLY 2.00 i i CHARGES
CONNECTION CHARGE FEE
OWNER'S FEIII'JTII' 5---tGo
—
AUTHORIZATION TOTAL FELE i REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTEDL 7'r,E PEREIN NAMED CON- rt iLS �
TRACTOR 7"0 ONN CT THE ABOV: DESCRI 'EX NNG DWELLING APPROVALS DATE iNSPECTOR'S 1('NATURE
I/ - ----- -.
70 THE PUBLIC S 'R � --'--
j6✓ ..kS.7USE SES`E
SIGNED THIS_ DAY
:� CONNECT ADDITIONAL
OWNER OR ,.-_ BUILDING OF NORK
SEPfiC TANKSEEP, PIT($)
ADDRESS. '' ". __� ANDIOR DRAIN (FL.D .. ._ .
1 HERiCEY ACKNOWLEDGE THAI' I HANE READ THIS APPLICATION CE SPOOL 0 DRYWELL[]
AND SPAT: THAT THE ABOVE 1S CORRECT' AND AGREE TO COMPLY
W;TH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I ,t REBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE AT AVE ABANDON HOUSE SEWER
DESCRIBED RESIDENT! ROP£RTY. v P"' BACKFILL SEPTIC TANKS
AT(
� :.,� SEEP PIS) CI CESSPOOLS
SIGNATURE
OF PERMiTTE A&le
WILLIAM J. FOX.COUNTY 2EN-01NEER VALIDATI®N
9Y as BY
DEPUTY DEPUTY
BI' BY �: 1 ;�,,,
DEPUTY x DEPUTY