HomeMy Public PortalAbout5218 MCCLINTOCK AVE_Sewer__ DEPARTB ENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
BUILDINWILLIAM J. FOX, COUNTY ENGINEER I ADDRESS ,sp� �I�,CReif.•5�•
FOR APPLICANT TO FILL IN I LOCALITY
BUILDING y ' NEAREST
ADDRESS . ) sZ/ rC-�J �/'/�l°t c....:.. "I-r GROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST �77
CROSS ST.
-� C VED
� Ready for Inspection /DATE ISSUED
OWNER
ADDRESS '� [� G/� ! _ I1y}E!OyE OCCUPANCY BK MAP Q
i Y+
CITY f ^• �/� /`y=;TEL.NO. ��. � LGA/�
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CONTRACTOR CO.IMP.N0.
ADDRESS I JOB N0.
CITY TEL.NO. ! TRUNK PERMIT NO.
STATE '
REGISTRATION NO. COUNTY' ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. i PERMIT NO.
BLOCK TRACT ` �� I INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS. `'
NOW ON LOT J .., A ES
USE OF —� `
BUILDINGS ,'/ice i/ o p���r r% ;J j CONNECTION CHARGE F4E
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FFi
HOUSE SEWER CONNECTING TO y�
PUBLIC SEWER a $ 3.50 RECEIPT N0. I DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 '
CONNECT ADDITIONAL BLDII.OR EXCEPTION RECORD)ED
WORK TO HOUSE SEWER 1.00 NO.. I DATE I BY
ALTER OR REPAIR EXISTING
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 R 74•7S DEPTH
CESSPOOL—DRYWELL -
SPECIAL CONDITIONS ONLY 2.001� I/) MANHOLE REFERENCE
I 41SREAr LOWER
TYPE OFCONJIECTION LENGTH FROM O
OWNERS PERMIT ; I 00 -y— `ARB- P.L. M.L.TO.P.L. a o
AUTHORIZATION I TOTAL FEE
IHAVE 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...... 19 NEW HOUSE SEWER :,•�.+!+••� le �l�
OWNER OR CONNECT ADDITIONAL '
OWNERS AGENT......._.._.._..___.._.._......_�.....�._.._. BUILDING OR WORK
PTIC
AND/OR DRAINFIELD PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[] DRYWELL
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
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ,/ �
SIGNATURE SEEP.PIT(S) CESSPOOLS
OF PERMITTEE...-- - .2.�=.(� .�_^. •
70A042A 663 7/53 O�