HomeMy Public PortalAbout5225 MCCLINTOCK AVE_Sewer__ DEPARTNEMNT OF COUNTY ENGINEM SEWER—SEWAGE DISPOSAL
1 DIVISION OF BUILDING AND SAFETY PERMIT APPLICATIO3386
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
_ADDRESS !' � ;- Ly �/✓ ?iA t' :a.e�.c =��
FOR APPLICANT TO FILL IN LOCALITYBUILDING
ADDRESS 5225 N 0 Clintock St. NEAREST
CROSS ST.
LOCALITYE+1 MOnt®
DISTRICT NO. SERIAL NO. PERMIT NO.
NEARESTy �, A ✓ `l
CROSS ST. G__ , e rr. e�t fR s
IVED BY Ready for Inspection DATE ISSUED
R
OWNER Vernall Chaplin eMAIL
ADDRESS Same USE ZONE OCCUPANCY MAP
i BK PG
CITY TEL.NO. / 9 ) /'r '
CONTRACTOR. CO.IMP.NO.
ADDRESS
JOB N0.
CITY TEL.NO. TRUNK PERMIT NO.
STATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO.
�p BLOCK TRACT / INDUSTRIAL
d v WASTE APPROVAL
NO
1J SIZE OF LOTS C NOW ON LOTS �- CHARGES
USE OF
BUILDINGS ties CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER a 5 8.50 3.50 RECEIPT NO. I DATE I 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/OR DRAINFIELD 2.00 STATION & DEPTH /
CESSPOOL—O RYW ELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFE.)(k!jC P
U`^t2 it [`,f LOWER
Y. TYPE OF
CURB CONNECTION .L. M.L.LENTO FROM
y —v /
OWNERS PERMIT ; I 00
AUTHORIZATION I TOTAL FEE 1 4.50
I 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_ — 1 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT 1 Al .._... _. _.—. „ BUILDING OR WORK
__. ..—
ADDRESS..._...... ..o_� SEPTIC TANK,SEEP.PITS)
�y-- --•--• •---- •- AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPL 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
1 HEREBY CERTIFY THAT 1 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 ESCRIBED R.SIDENTIAL PROPT BACKFILL SEPTIC TANKS
' SEEP.PIT(S)[] CESSPOOLS
SIGNATURE
OF PERMITTEE.. .-...e.._:..... /�/
f
7GA642A 663 7/53 '�: