HomeMy Public PortalAbout10781 BLACKLEY ST_Sewer__ ®® (q_® pr's meq( PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
-% Department of County Engineer
County Of Los Angeles BUILDING
` WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITYNEAREST IV
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FOR APPLICANT TO FILL IN CROSS ST, ;jj C,S
LEGAL EY
DESCRIPTION LOT NO. I Iv? OWNER
BLOCK' /yTRACT �j �J 1� /
ADDRESS
(/ ��0 NOW ONNO. OF /
SIZE OF LOT CITY & d!JEL. NO. 0 I6
USE OF
BUILDINGS Ave-5 1,1ea- - c— `� DISTRICT NO. G OUP MAP
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CONTRACTOR Q aIII/-elt, ^ 41/ � I C_-: A,
ADDRESS / �IC J CONNECTION DATA
CITY, TEL. NO. Q.- J STATION DEPTH
1 ❑ STATE MANHOLE REFERENCE
REGISTRATION NO. `,P COUNTY UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
NO. DESCRIPTION OF WORK FEE Y. CURB P.L. M.L.TO P.L.
1
HOUSE SEWER CONNECTING TO ��/„/ /r� �����T
PUBLIC SEWER' Q $ 3.50 f-+ r--�-
HOUSE SEWER CONNECTING TO \ ti
_ PRIVATE DISPOSAL SYSTEM 1.00 i
CONNECT ADDITIONAL BLDG. OR �P CO. IMP. NO. JOB. NO.
WORK TO.HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
_ SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT N0.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
_ AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL '
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEEfps REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE.HEREIN NAMED (CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED,EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF6 _�__/Q�, 19- NEW HOUSE SEWER
OWNER . OR �� ,['/ CONECT ADDITIONAL
OWNER
AGENT � BUINLDING OR WORK _ N
SEPTIC TANK, SEEP, PIT(S)
ADDRESS - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ _ -
AND STATE THAT THE ABOVE IS 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 I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR-THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. ,(J/ BACKFILL SEP❑C TANKS El ❑
SIGNATURE `�•_ '� ,`
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
L BY DEPUTY DEPUTY
,�, 07 6 B4 C SEP 7 4 2.0 0 H1
C
BY BY ` f
Q DEPUTY DEPUTY 6/