HomeMy Public PortalAbout5232 MCCLINTOCK AVE_Sewer__ DEPARTMENT OF COUNTY ENGMEM SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS "GEMM
WILLIAM J. FOX, COUNTY ENGINEER ADDREISS
FOR APPLICANT TO FILL IN LOCALITY
BUILDADDRESNG S .S Ja /e/ / / SCI//��rNEAREST
d G CROSS ST.
LOCALITY f/i)u G C % DISTRICT NO. Ready for Inspection (PERMIT NO. c
NEAREST � r?6 r�9 J
CR0888T. 1P Get R EIVED B y DATE 1 U BY .{ q ATE
OWNER To G AlMAIL /� � �1� �✓���c�("O
ADDRESS �'. J� /!�/1/%O � SE ZONE' OCCUPANCY BK MAP PO
CITY �°pjr,?& TEL OO. e& r 70 eb5
CONTRACTOR () k;/1/I*;-
CO.IMP.N0.
ADDRESS
JOB.NO.
CITY TEL.NO. TRUNK PERMIT NO. '
STATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. g PERMIT NO.
BLOCK TRACT 3 INDUSTRIAL
2�y / , WASTE APPROVAL
SIZE OF LOT NO.OF BLDGB. hr � y+ CHARR
NOW ON LOT �„1 p:► Ln1lG`
USE OF
BUILDINGS f/Ct/N %�y� CONNECTION CHARGE FEE
NO. DEEICRIFTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER ! ; 3.39 7 cd RECEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR CEPTION RECORDE
_WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING �• I DATE BY
_ SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 �C7OoNNNECTION DATA /
SEPTIC TANK.SEEPAGE PIT OR (Q
_ PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYW ELL
SPECIAL CONDITIONS ONLY 2.00 �/ MANBP LEPER
RREFERENCE
TYPE OF CONNECTION LENGTH FROM R
OWNERS : I 00
_fa� .CUA'— P.L. M.L.TO P.L. ,/
PERMIT
AUTHORIZATION I TOTAL FEE c50
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGAPPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER o
SIGNED THIS. DAY OF i�% 19.3 NEW HOUSE SEWER �,•?e.,e' .
ER IL CONNECT ADDITIONAL
OWN
ER BUILDING OR WORK
! SEPTIC TANK.SEEP.PIT(S)
ADDRESS_.`°2_ cl L �t� _.G ._..� AND/ORDRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL
CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE•DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED '
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED REBID NT IAL ROPERTY. BACKFILL SEPTIC TANKS
�i�� r SEEP.PIT(S)[] CESSPOOLS 05
OF PERMRITTEE. �v�C_&.- w.
70A6421) S&E 663 4/54