HomeMy Public PortalAbout5131 MCCLINTOCK AVE_Sewer__ HDEPAUTRIW4 OF COUMM ENQnUMB SEWER-SEWAGE DISPOSAL. 4
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DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION 1
COIIN'3.'Y OF LOS ANGMIMS gU1LDING
WILLIAM J. FOX, COUNTY ENGINEER I ADDRESS ,� �' C AINnC
FOR APPLICANT TO FI IN LOCALITY
BUILDING I NEAREST
ADDRESS (moi 1p s/y -(' CROSS ST.
LOCALITY r= R X IF1� •:�_ h r DISTRICTNO. p A SERIAL N0. PERMIT N0.
NEAREST ���
CROSS ST.
_m II
- RECEIVED BY Ready for Inspeatlon DATE ISSUED
OWNER :n A :rN .41 0 i MAIL id, s
ADDRESS �v M USE ZONE OCCUPANCY r^ BK MAP PG
CITY TELAO. - .�•
'42
CONTRACTOC;li f ornia CO.IMP.NO.
ADDRESS ' ` "�' �•-
I.' 7 JOB NO.
CITY rj TEL.1110. PIA r- TRUNK PER IT NO.
REGISTRATION NO. ® COUNTY
��++ ROAD PERMIT N -N,
LEGADESCRIPTION LOT NO.-S- !1 � STATE ENCROACHM T
�/ ae PERMIT NO.
BLOCK TRACT/ e T/�'�v'�S'� INDUSTRIAL
J+ WASTE APPROVAL
SIZE OF LOT NOOF
ON LOTS• L
CH ES
USEOF
BUILDINGS �- �_ CONNECTION ARGE FEE
i NO. DESCRIPTION OF WORK FEE REIMBU EMENT FEE
HOUSE SEWER CONNECTING TO c� r
PUBLIC SEWER @ $ 3.30 CEIPT NO. I DATE 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 NO. I DATE I 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/ORDRAINFIELD 2.00 STATION � / DEPTH
CESSPOOL—O RY W ELL
SPECIAL CONDITIONS ONLY 2.00 O 9 .—MANHOLE REFERENCE
LOWER'
TYPE OF CONNECTION NGTH FROM c� 4
OWNERS
PERMIT $ 1 00 Y. CURB P.L. M.L.TO P.L. 62®
AUTHORIZATION TOTAL FEE !� /
1 HAVE THIS DATE CONTRACTED WITH THE HER IN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO Te�HE�PnUBLIC SEWER
SIGNED THIS.__Y_..lY Y O ... _19, NEW HOUSE SEWER
OWNER OR - CONNECT ADDITIONAL
OWNERS AGENT..._ .. _ ... .. BUILDING OR WORK
PTIC ADDRESS... (.._ .._......_.._......_... AND/OR DRAINF ELD PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL I]
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
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERNTY ED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DE CR ED ESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)[] CESSPOOLS
OF PERMITTEE.. . _. .._� `�
76AS42A 663 7/53 p
76A642D
CEB°e'REvfts .°"�' APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. I GROUP 8K PG MAP PROCESSED BY
BUILDING (�� 7 /�`_ �qb C�j/l L.
ADDRESS s4-:= Y ` IG
LOCALITY CONNECTION DATA
NEAREST STATION DEPTH
CROSS ST.
UPPER
MANHOLE REFERENCE LOWER
OWNER ��,//` 1�C' „�S (.. -' / L - TYPE OF CONNECTION LENGTH FROM
MAIL Y. CURB P.L. M.L.TO P.L.
ADDRESS ._ ('~ j""[Jc
P.G.NO.
CITYEGAL '.:� '.' TEL.NO. S/ 7
l� CO.IMP.NO. JOB NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR,NO. DATE
BLOCK TRACT
NO.OF SLOGS,
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO,
INDUSTRIAL
CONTRACTOR WASTE APPROVAL
ADDRESS CHARGES
CfTY TEL.NO. CONNECTION CHARGE FEE
STATE LIC. REIMBURSEMENT FEE
LICENSE NO. CLASS o
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO ca
O
PUBLIC SEWER
SEPTIC TANK.SEEPAGE PIT OR NEW HOUSE SEWER
ITS AND/OR DRAINFIELD CONNECT ADDITIONAL y
HOUSE SEWER CONNECTING TO BUILDING OR WORK 1IOO���i
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK.SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER AND/OR DRAINFIELD _
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL❑
EXTN..CESSPOOL,DRYWELL,MANHOLE
ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
L' � (�.i� ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑ _
OWNER'S Permit a '7SEEP.PIT(S)❑ CESSPOOLS
AUTHORIZATION TOTAL FEE J VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. _
SIGNEDTHIS y-•- DAY OF 19
OWNER OR
OWNERS AGENT
ADDRESS � y�
I HEREBY A NOWLE DGE THAT I HAVE READ THIS APPLICATION
AND STATE TH T THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO RE-
SIDE IN.THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE wl
OF PERMITTEE