HomeMy Public PortalAbout9114 BLACKLEY ST_Sewer__ DEPARTDEENT OF COUNTY ENGINEM 1 7_' /.3/ �¢e�v
SElOi6ER-�SEW,4C E 'DISPOSAL
DNISIOFT OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY EN13INEER BUILDING // [�[ ✓ I
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LOCALITY 70,
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CROSS ST
RECEIVED BY Ready for Inspection DATE
ISSU_ED`
OWNER
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ADDRESS
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CITYEL NO TRUNK PERMIT NO
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REGISTRATION NO // "7 ROAD PERMIT NO
LEGAL STATE ENCROA\HMENT
DESCRIPTION LOT NO PERMIT NO
BLOCK TRACT INDUS RIAL
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SIZE OF LOTUSCOF NOW ON LOTT -CHARGES /
BUILDINGS gj S CONNECTION CHARGE FEE\
NO DESCRIPTION OF WORK FEE REIMBURSEMENT FEE \
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 350 1 RECEIPT NO ( D_AfE I BY -
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00 x
r( CONNECT ADDITIONAL BLDG OR EXCEPTION/RECORDED
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING NO I DATE I BY
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONN CTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 200 STATION / DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 MANHOLE REFERENCE /
UPPER z LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ I 00 Y CURS IPL M L TOP L
AUTHORIZATION TOTAL FEE ac I
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I HAVE THIS DATE CONTRACTED WITH THE HERIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER cc
SIGNED THIS DAY OF ___ 19s�3 NEW HOUSE SEW ER _
1�' /, CONNECT ADDITIONAL
OWNERS AGENT J� ��/ /�1¢'7� r BUILDING OR WORK � � ��,,, �A
SEPTIC TANK,SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD '
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL[:] DRYWELL
CATIONAND STATE THAT THE ABOVE IS CORRECT , AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR,SEWER OR
RECULAT�NG PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OP. LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF C LIF RNI THAT I AM THE LEGAL OWN-
ER OF THE A SCR RESIDENTIAL RO ERTY BACKFILL SEPTIC TANKS
SIGNATURE SEEP PIT(S)Ej CESSPOOLS❑
OF PERMITTEE
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