HomeMy Public PortalAbout5211 MCCLINTOCK AVE_Sewer__ 78A6420
s.3s�tt.ss APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDINGJ
JOHN A. LA.MBIE, COUNTY ENGINEER ADDRESS r
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY _
- NEAREST
FOR APPLICANT TO FILL IN CROSS ST,
LEGAL —.—".�— — -- OWNER
DESCRIPTION LOT NO. MAI 0
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BLOCK TRACTAIA ADDRESS s._
NO. OF BLDGS, CITY TEL. NO _�.Z
SIZE OF L_O_T NOW ON LOT
USE OF _' .,, �--- -------
BUILDINGS_ `'' DI,STRICT NO, CROUP MAP
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CONTRACTORy,..
ADDRESS 7 CONNECTION DATA
STATION EPTH
CIT Y TEL. NO. _—�d's'a� -�j' lr�+ D
— - MANHOLE REFERENCE � 'UPPER
TATE _,,,� ✓ r�►--b6 r f - "� '
REGISTRATION N0. COUNTY — --
NO,_.[ DESCRIMON OF WORK FEE
--_ —� - -- -_----" --- —.r TYPE OF CONNECTION LENGTH FROM a
_1 HOUSSEWER CONNECTING TO ( Y, CURB F''D., M.L.TO P.L.
I—AUBLIC_SEWER — @_$3_S — --- -- —^ ---
I SEPTIC TANK,SEEPAGE PIT OR
_— PITS AND/OR DRAINFIELD @ $:3_00I '— --�
!—OVERFLOW SEEPAGE PIT,DRAINFIELD _ NO. I'. C. NO. —�--
_ EXTN.,CESSPOOL,DRY V.'LL,MANHOLE (�� $2.00� CO._iMP. NO.�+ .; JOB NO.
HOUSE SEWER CONNECTING TO Jv i j
j PRIVATE DISPOSAL SYSTEM _ C $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. _
CONNECT ADDITIONAL BLDG.OR ( STATE ENCROACHMENT
WORK TO HOUSE SEWER re $I.OD PERMIT NO.
i—..-- -----------------------------�_--:—_—_ -- - ----------- -- - -- ---
ALTER,REPAIR OP ABANDON HOUSE
INDUSTRIAL
_
SEWER OR DISPOSAL SYSTEM ��_ $1.0,3
-- - _---- WASTE APPROVAL -
CHARGES
CONNECTION CHARGE FEE
OWNER°S PERMIT r t i pp - - —.REIMBURSE-MENT FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRA T W,'TH IHE HEREIN NAMED CON- APPROVALS _ DATE }1N5PECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS_' DAY OF �� A -- --- --
—r--- 1�'�-- - CONNECT ADDITIONAL
OWNER OR7' ✓+. BUILDING OR WORK ---_._,--�
—� — --
OWTdiRS AGENT �'"' ''� � � � P.� a - - ---
. -- SEPTIC TANK,SEEP,PIT(S)
ADDRkSS _ �`3 _ AND/OR DRAINFIELD 1
HEREBY AC NC01LEDGE THAT 1 HATE READ THIS APPLICATION CESSPOOL❑ DRYWELL O j
AND STATE THAI' THE ABOVE IS CORRECT AND A REE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR -`---------
LICENSED AS REQUIRED BY LOSNGF.LES COUNTY A STALE OF ABANDON HOUSF�`EWCR 1
CALIFORNIA OR T T -M�'d LEG n OWNER THE --- ---- ----
DES"C YBACKFI'L SEPTIC TANKS Ll
SE'?' PIT(S) L2 CESSPOOLSL
OF PERMITTEE 'I ✓ .. t -_.
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JOHN A. LAMBIE,COUNTY ENGINFER VALIDATION FC
ROBET i;t10L)
A. 0 ,CHIEF'PL8G.. INSPECTOR
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