HomeMy Public PortalAbout9123 BLACKLEY ST_Sewer__ 5-65
76A645-65
APPLICATION FOR PERMI
76A 64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOAN A 1 AMBIF County Fngmeer ADDRESS
COLLNIAN W JENKINS, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FML IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER,
MAIL
BLOCK TRACT � ADDRESS OC/
NO OF BLDG5 4
SIZE OF LOT NOW ON LOT CIT L NO
USE I DISTRICT NO sl GROUP MAP PROCESSED BY
BUILDINGS
f/A� BK PG I
CONTRACTOR J"Ity
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ADDRESS CO ECTION DATA
STATION DEPTH
CITY TEL NO
LICENSE LICENSE UPPER
NO CLASS MANHOLE REFERENCE
r
NO,, DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH ROM
HOUSE SEWER CONNECTING TO '� Y CURB PL ML TO L
PUBLIC SEWER C $ 5 00 (/ V
SEPTIC TANK SEEPAGE PIT OR - O PC NO CL
PITS AND/OR DRAINFIELD @ $1 0 00 CO IMP NO JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO U
PRIVATE DISPOSAL SYSTEM C' $ 3 00 OC
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT [RECORD INSTR NO DATE O
WORK TO HOUSE SEWER P $ 3 00 0
RE R ABANDON N HOUSE U
SEWER OR DISPOSAL SYSTEM C $ 3 00 W
'EPITHWY OR ST WIDENING d
N
EXTN CESSPOOL MANHOLE C� $ 5 00 STATE ENCROACHMENT Z
I PERCOLATION TEST F $ 5 OG PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s z Oo CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED"CONN REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_ A
OWNER OR NEW HOUSE SEWER -
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
I HFREBY ACKNOWLEDGE THAT I 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 ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED LOS ANGLES COUNTY AND STATE F SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT [/AM HE LEG OW R AND INTEN O DISCONNECT PLUG AND
RESIDE IN THE AB CRI BE 1 ROPER ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑ �� J�!{� `
OF PERM ITTEE SEEP PIT(S) ❑ CESSPOOLS ❑ ��!/�/,
VALIDATION--, /
CK M O CASH
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