HomeMy Public PortalAbout10787 BLACKLEY ST_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
sDIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I ADDBUILRDIESSNG <9^
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FOR APPLICANT TO FILL IN LOCALITY �� �/� Xy-
ADDRESSBUILDING C CROSS ST. `( cc, �// C f�
LOCALITY DISTRICT NO. SERIAL N0/.n PERMIT NO. f c
NEAREST 44 V ^TMJ
CROSS ST. / r �/��IZ6 C ` l� R ECEEIIV�ED�BYY Ready for Inspection DATEISSUED
OWNER 0j_ 0, C�� y-�� iJ��yW'(/yl�
MAIL /O 7?-7 �' ���r ;J/_r USE LONE OCCUPANCY BK NN1�PG
ADDRESS ��T '/�([ J /
CITY �/� �l L V EL.NO. �C� Jws?
CONTRACTOR �J2 e2 CO.IMP.NO.
ADDRESSJ O B
'N 0. V lCli/
CITY TEL.NO. TRUNK PERMIT NO.
STATE `
REGISTRATION N0. COUNTY ROAD PERMIT N0. /
LEGAL STATE ENCROACHMENT /
DESCRIPTION LOT NO. PERMIT NO. V
BLOCK TRACT / 3 INDUSTRIAL /\
WASTE APPROVAL
SIZE OF LOTNL
�pU x Q� NO0.WOF ONBLOTDGS. / C ARGES)
USE OF
BUILDINGS �� 5/ f�P�/JC'Q! CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLICSEWER @ $ 3.50 RECEIPT NO. /I DATE\ I BY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSALSYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR �/ EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 r
ALTER OR REPAIR EXISTING / NO. IDATE 1 I BY
SEWER OR DISPOSAL SYSTEM 1.00 f/
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DADA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATIO DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 / MANE
UPPER EFERENCLOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 00- Y. CURB - P.LL.. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE aZ 00 f hod,",
I
1 HAVE THIS DATE.CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS--------------------DAY OF-------___--_-_--__-_-.____.__._..... 19____.. NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL D ✓ e71y}��
OWNERS AGENT-------------------_ •_ BUILDING OR WORK ✓V�L�My✓ / vY
SEPTIC TANK,SEEP.PIT(S)
ADDRESS--------------------------------------------------••-•----•---_.......................-•-- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL I] DRYWELL E]CATION AND STATE THAT THE ABOVE IS 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 IAM 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 ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFI LL SEPTIC TANKS E]
SIGNATURE �/ SEEP.PIT(S)Ej CESSPOOLS[ ,
OF PERMITTEE=__•tel_.-�`. ....-- _--_-----•------- �g
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