HomeMy Public PortalAbout9109 BLACKLEY ST_Sewer__ APPLICATION FOR PERMIT-
OF s=MG AND SAFETY SEWER—SEWAGE DISPOSAL
Cc=jy of Los Ang4am BDILDING
JOHN A. LAMBIE, CbuNTY ENOINHER ADDRESS
T CA8SATTD. GRIPTIN, SUPT OF BUILDING LOCALITY G,
r
FOR APPIXANT TO FILL IN "c,IEos
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL'
BLOCK TRACT ADDRESS
IZE OF LOT
NO. OF BLDG!!.
N OR LOT C1TY TEL. NO.
USE OF _ DISTRI H0. G120UP MAP
BUILDINGS
BK PG
CONTRACTOR
ADDRESS CO ON DATA
vv ATION DEPTH
CITY TEL. NO. MANHOLE REFERENCE _ UPPER
❑ STATE LOWER
REGISTRATION NO. ❑ COUNTY -
No. DESCRIPTION OF WORK FEE
HOUSES CONNECTING T PE OF CONNECTION LENGTH FROM
PUBLIC SEWER B X• CUR P.L. Y.L.TO P.L. ,
SEPTIC TANK,SEEPAGE PIT OR ,
PITS AMD OR DRAINFIELD 5.00
d'VERFLOM 0 PAGE PLT,DRAM IELB CO. IMP. 110. JOB No.
.
EXTN.,CES8P00 ,DRYMELL ILS 2A0
HOSH EEM ER CONNECTING TO
PR A ISP SAL SYSTEM @ 11.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ S 1.00 PERMIT NO,
MTN ABAJIDON HOUSE __11 I#n1' I�
DISPOSAL SYSTEM 1.00 W 1 APPROYAL
CHARGE$
CONNECTION CHARGE FEE
OWNER'S PEEWT s 00
A'QTHORIY.ATION TOTAL Fa REIMeU■RBE�MENT.FB�[ET C
I HAVE AT THIS DATE /� CONIRACT WITH THE HEREIN NAMED COM_ APPROVALS DATE INSFECTOA'SSIBNATURE
TRACTOR TO CONNECT TH6 ABOVE DESCRIBED EXISTING DWE MNG
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS SAY OF 19 CONNECT ADDITIONAL
OWNER OR _ BUILDING OR WORK
OWNERS AGEIIT SEPTIC TANK,SEEP,PIT{S)
ADDR ASID/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPQOL❑ DRYWELL❑
AND STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER-OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AIT PROPERLY REGISTERED AND/OR DI/CONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AMP STATE OF ARDOR H USES ER
CALIFORNIA OR THA I AN THEE _
,, LEGAL OWNER OF THE ABOVE _
DESCRIBED RESIDEN't L ROPERTY. It CKFILL
(( ESS OOLS
1H:NATgPE -
OF PERYFTTEE
JOHN A. LAMS E, C�OIJNTY ENOINHER VALIDATIO ROBERT A.WOOD, PIECTOR
= 9 ,°t .An 3 0 1, 0 A
. 3.0 0 �.
r
1150
7aA"XD APPLICATION FOR PERMl' '
a a Ic.eea tt-an 7
DIYffiION OF B=ING AND SAFETY SEWER—SEWAGE DISPOSAL 1
Depaztment of Co—tr F-gh .r
DIY o{ Lm &wm]M FADDRIESS
IRG
JOHN A. LAMBIE, CouNrY ENOINtl[R
m CASSAT7 D.GRIFFIN, SUI+'T of IBUILDIP40
LITY
ILUEST
FOR LICANT TO FELL IN CROSS SST.
LEGAL
DESCRIPTION T Q•XER A
MAIL
BLOCK CT ADDRESS
XO,OF BLDG$. CITY TEL. N0.
SIZE OF LOT NOW ON LOT
USEOF
BUILDINGS
DI DISTR�O.. GROUP MAP
BUILDING>i �— BK PG
CONTRACTOR CALIF.SEWER CONST.CO
ADDRESS 1317 COLEGROVE AVE. CONNECTION DATA
CITY MONTEB-ELLgL. N4. PA. 1-5048 STATION 3�>r DEPTH
MANHOLE REFERENCE UPPER
180767 TATE ❑ STATE
REGISTRATION NO. ElCOUHTY
No. DESCRIPTION OF WORK FEE
HOUSE SERER CONNECTING TO TYPE OF CONNHCTIO LENGTHFROM �{
PUBLIC SEVER 3 Q O Y. CURB .L. Y.L.TO P.L. (J
SEPTIC TANK,SEEPAG9 PIT OR
PITS AND/OR DRAINFIELD @ 9.00 -
OVERFLOW SEEPAGE PIT,DRAINFIELDP. C. N0. _
I
❑(TN. POO L,DRYVI 4 LL 1 2,00 CO. IMP,XO. Z&A JOB X0.
I HOUSE SEWER CONNECTING TO
I PRIVATE DISPOSAL$YfrTEY 1.00 TRUNK PERMIT N0, ROAD PERMIT XO_
CONNECTADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE
OUB SEWER ® Z 1.00 PERMIT X0.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM 11.00 WAM APPROVAL
CHARGES
' CONNECTION CHARGE,FEE
OWNERS pEamrr 00
.ATION FFA REIYBURSITYENT FEE-
ADTHOHI7TOTAL ,
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED Com—
TRACTOR TO CONNECT THE ABOVE DESCRIBED�ISTINB�H��NG I
TO THE PUBLIC NEW HOUSE SEWER
SIGNED THISAY 19 CONNECT ADDITIONAL r
OWNER OR BUILDING OR WORK
OWNERS AG SEPTIC TANK,SEEP,PIT($)
ADD AXD/OR DRAINFIELD
T HEREBY AC FLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE 1E CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM _
I HEREBY CERTIFY THA Y PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRE LO A EL COURTY AAD STATE OF
CALIFORNIA• OR THA'
H 1 AY G OrXER F THE ABOVE ABANDON HOUSE SEIYER.
DESCRIBED RESIDE AlP - BACKFILL SEPTIC TAKXS❑'
SIGNATURE' SEEP.PITS) ❑ CESS POO ❑
OF PERMITTEE -
JOHN A. LAMPIE, Cou EIER /-^�/ALIDATION ROBERT A.WOOD, CHIKF PL.HO. INSPECTOR'
� ,o5 9 0 2 � APR 1 0 A 5.00