HomeMy Public PortalAbout9121 BLACKLEY ST_Sewer__ 12 eB APPLICATION FOR PE NIIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION [ADDRESS
u ILOING
JOHN A LAMBIE, COUNTY ENGINEER COLEMAN W JENKINS SUP T OF BUILDINGOCALITYEARESTFOR APPLICANT TO FILL IN ROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGB r /�
SIZE OF LOT NOW ON LOT CITY TEL N (�
Ir-
USE OF
BUILDINGS DISTRICT NO EOUP BK PG
MAP PROCESSED BY
CONTRALTO
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ADDRESS COIMCTION DATA
CITYL NO /b STATION ` DEPTH
STATE LIC MANHOLE REFERENCE c•P e-uPPEFj
LICENSE NO CLASS 3 {
NO bEStRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM ♦
HOUSE SEWER CONNECTING TO Y CURB P M L TO P L iV
PUBLIC SEWER $5 00 PC NO
SEPTIC TANK S EPAGE PIT OR CO IMP NO JOB NO
PITS AND/OR DR
AINFIELD SIO 00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM s3 00 (_
CONNECT ADDITIONAL BLDG OR IVEE EASEYENT RECORD INSTR NO DATE V
WORK TO HOUSE SEWER @ 5300
OVERFLOW SEEPAGE PIT DRAINFIELD CD
EXTN CESSPOOL DRYWELL MANHOLE @ 5500 I-_
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING W
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT CL.
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT s i o0
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR T0.CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSP OR S SI N TORE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER D 6
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANKSEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
LRESIDE
CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM "
OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
HE ABOVE DES ISEDRESIDENTIAL PROPRTY ABANDON HOUSE SEWER
TE BACKFILL SEPTIC TANKS
SEEP Pit s) ❑ CESSP LS ❑ 7Q
VALIDATION JACK R. ALLEN
CK SUPERVISING MECHANICAL ENGINEER
M O CASH
1kr„4 7 1 59 WR29 1 0 D 7.00
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