HomeMy Public PortalAbout5233 MCCLINTOCK AVE_Sewer__ 1)EPAk'lMZNT :OF COU11= ENGngK= SEWER-SEWAGE DISPOSAL
,A? VISION OF BUILDING AND SAFETY CATION
PERMIT APPLICATION
OUBM OF LOS ANGELES -BUILDING
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WILLIAM J: FOX, COUNTY ENGINEER ADDRESS � p '-�(,'
FOR APPLICANT TO FILL IN LOCALITY _ [� - _-'
BUILDING. NEAREST
ADDRESS� r 3 ®j Q(4 CROSS ST. .t7.✓1--
LOCALITY DISTRICT NO. p 'SERIAL NO. PERMIT NO'. c
NEAREST — r A V S
CROSS ST. _ RECEIVED BY Ready for Inspection DATE ISSUED
OWNER !� / / p.. l s�` ?w-�
ADDRESS gC 7 ' p G USESNE OCCUPANCY BK MAP PG
CITY /7�_d +-
CONTRACTOR
ADDRESS
JOB NO.
CITY ro, /it;TELAO.. f, m TRUNK PERMIT NO.
Q � ►/y 6ry�- B STATE
REGISTRATION N0. 7 COUNTY ROAD PERMIT N0. _
LEGAL STATE ENCROA MENT
DESCRIPTION LOT N0. ® PERMIT NO.
BLOCK TRACT f �� INDUSTRIAL
WASTE APPROVAL
0
SIZE OF LOT (� N0.OF BLOGB: h� p
_ NOW ON LOT
USE OF /
BUILDINGS S/, Q p"G nyJ �Q,I�p,of T; CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO �O REIMBURSEMENT FEE
PUBLICSEWER• @ $ 8.50. RECEIPT NO. DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM I:00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00i N0. I DATE
ALTER OR REPAIR EXISTING.
SEWER OR DISPOSAL SYSTEM 1.00
AND/OR DISPOSAL YSDISCONNECT AND TEM$ EWER 1.00 CONNECTION DATA
SEPTICTANK,SEEPAGE PIT OR'
PITS AND/ORD.RAINFIELD 2.00 STATIONfG� DEPTH
CESSPOOL—DRYW ELL
SPECIAL CONDITIONS ONLY 2.00' NHOLEREFERENCE UPPER KKR
_ TYPE OF CONNEtTIO LENGTH.FROM y�
OWNERS PERMIT I 00 Y. CURB P.L. I M.L.TO P.L. .G
AUTHORIZATION I TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATUREDATE
DWELLING- TO THE PUBLIC SEWER
SIGNED THIS_ NEW HOUSE SEWER THIS--.---..DAY
OF_.._...._._ _ .._.__ ��
BUILDING OR WORK
OWOR CONNECT ADDITIONAL
NER
OWNERS AGENT—_-.--__—._ _ w_ _._.___
SEPTIC TANK,SEEP.PIT(S)
____. __.�_. ._......_.._..__._.._:. . AND/OR DRAINFIELD
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 DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF.CALIFORNIA OR THAT I.AM THE LEGAL OWN-
ER OF THE.ABOV DESCR ED ESIDENTIAaPROPETY. BACKFILL SEPTIC TANKSSIGNATURESEEP.PIT(S)[] CESSPOOLSOF PERMITTEE
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