HomeMy Public PortalAbout5515 MCCLINTOCK AVE_Sewer__ 3 Ae4-n•
1APPLICATION FOR PERMIT 1
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,r DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
2' t JOHN A. LAMBIE, COUNTY ENGINEER P_DDRESS "A.:7'r _ J!' �+�, � ,s"_ I
CASSATT D. GR
IFFIN, OUP'T OF BUILDINGLOCltLI fY 6.
FOR APPLICANT TO FILL IN CROSS ST.LEGALDESCRIPTION LOT NO. OWNERMAILBLOCK TRACTADDRESSN0, OFBLDGS. - �rOF LOTNOW ON LOT CITYTEL. NO..f , ,€ ,,. !
USE OF --- -= by}` -- -----
BUILDINGS r' y, �1i ,c }y DISTRICT NO. GROUP I MAP
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CONTRACTOR
ADDRESSe T •' x —__--i_CONNECTION DATA ---
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CITY ,T STATION---- — DEPTH _
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MANHOLE REFERENCE _UPPER
-� [J STATE _ LOWER
REGISTRATION NO, _ COUNTY
Pio DESCRIPTION OF WORK -FEE TYPE OF CONNECTIO LENGTH FROM -
HOUSE SEWER CONNECTING TO Y. CURB P. -
PUBLIC SEWER
-------- ---- A---'M.L..L. O P.L.P.L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD r
j OVERFLOW SEEPAGE PIT,DRAINFIELD ` I C, NO.
EXTN.,.CE$SPOOL,DRYWELL,MANHOLE (q1 $2.001 1 CO_iMP. NO. _ .I N0.
j HOUSE SEWER CONNECTING TO {
PRIVATE DISPOSAL SYSTEM (a) $1.00 _ TRUNK PERMIT NO. ROA PERMIT NO.
CONNECT ADDITIONAL BLDG.OR I
' STATE ENCROACH MNT
WORK TO HOUSE SEWER Cro $1.00 1 ��- PERMIT N0,
ALTER,RRVA+R- {3lat,HOUSE --".-..-- ---- ---------_--
SEWER- .-- -- -M �ry_.i;.00 INDUSTRIAL
_-__ .-�_"__-. WASTE APPRO L
CHARGES
I
CONN ECTfON CHARGE FEE
OWNER'S � PERMIT — -- --- ------ - _..-----------'------....----
1 00
--- --------- - ----. REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. _.-_-..-_APPROVALS _ _ GATE -1INSPECTOR'S SIGNATURE
TRACTOR 'fOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. - NEW HOUSE SEWER
SIGNED THIS DAY QF _— .19._— CONNECT ADDITIONAL ---
OWNER OR BUILDING OR
OWNERS AGEN'i'--.__--.._—._. ,-W- SEPTIC TANK,SEEP, PIT(St
ADDRESS-_. ANDi OR DRAINFIELD ,
1 HEREBY .ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - E,
CESSPOOLL DRYV c1.L
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
P-LUMBING AND SEWERS. SEWAGE.DISPOSAL SYSTEM
1 HEREBY CERTIFY-THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND --_-
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE of ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER Or THE ABOVE ------ ._..
DESCRIBED RESIDENTIAL PROPERTY ,�! BACKFILL SEPTIC TANKS❑
r' SEEP.PIT(S) Q CESSPOOLS
SIGNATURE -
OF PERMITTEE ---
!OHN A. LAMBIE,COUNTY ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PL6G. INSPECTOR
CK. M.0:, CASH
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