HomeMy Public PortalAbout9117 BLACKLEY ST_Sewer__ CEBOB3 62
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W JENKINS SUP T OF BUILDING
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRDSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO I GROUP MAP I
ROCESSED BY
BUILDINGS PG
CONTRACTO ^sO
ADDRESS CONNECTION DATA
CIT EL NO STATION � DEPTH
STATE LIC ` ' MANHOLE REFERENCE(
LICENSE NO GLASS �/ `J a)� LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB L M L TO P L lO d
PUBLIC SEWER @ $5 00
41 SEPTIC TANK SEEPAGE PIT OR CO IMP NO Q P C NO
JOB No V
PITS AND/OR DRAINFIELD @ SIO 00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO O
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAlveN iASErENT RECORD INSTR NO DATE F-
WORK TO HOUSE SEWER @ $300 W
OVERFLOW SEEPAGE PIT DRAINFIELD d
EXTN CESSPOOL DRYWELL MANHOLE @ 35 00 to
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING Z
SEWER OR DISPOSAL SYSTEM @ $3 00 1 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS S 2 00 AUTHORIZATION[PERMIT
TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEW R E INS CTOR 5 SI NATURE
SIGNED THIS DAY OF 19_
NEW HOUSE SEWER
I
OWNER OR
OWNERS AGEN CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WIT HALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS - CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED By
LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYS TEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE VE D CRIBED RESIDEN IAL PROP RTY ABANDON HOUSE SEWER
SIGNATURE ❑
OF PERMIT BACKFILL SEPTIC TANKS
SEEP PIT(S) ❑ CESSPOOLS
VALIDATION JACK R ALLEN
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
ren 4 7 4 1 0 D 7.0 0rt �