HomeMy Public PortalAbout9206 BLACKLEY ST_Sewer__ FOR
Sa E-6D APPLICATION �uOR PERMIT' tq
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS CSS g j
® CASSATT D. GRIFFIN, SUPT OF BUILDING
LOCALITY
Q
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT NO. `
/ MAIL
BLOCK TRACT . ADDRESS
NO. OF BLDGS. CITY TEL. N0.
` SIZE OF LOT NOW ON LOT '
USE OF
BUILDINGS. - - DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR ®•-
ADDRESS �~ n
CONNECTION DATA
STATION CA 0 DEPTH 46
I T
MANHOLE REFERENCE 'n
y( ❑ STATE
REG.ISTR ION NO. j/ PJ ❑ COUNTY
NO: DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTIO LENGTH FROM
PUBLIC SEWER @ $3.50 Y' P L M L TO P.L.
/
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD CO. IMP. N0. 10B NO.�� ��7f�
EXTN.,CESSPOOL,DRYWELL,MANHOLE c{ $2.00
HOUSE SEWER CONNECTING TO /B 4J.71�16F cr 1,.?—It
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
ArCONNECT ADDITIONAL BLDG.OR /$ STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 _PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ t 00
� REIMBURSEMENT FEE '
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HERE[ AI _ APPROVALS DATE INSPECTORS SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EX STI 0 L
TO THE PUBLIC SEWEE_ ,;� ,� pp NEW HOUSE SEWER D��S„�',. .�y/9%;-•
SIGNED THIS .4e DAY OF 4�"J ���� 1J° •" CONNECT ADDITIONAL
OWNER OR �/R"� BUILDING OR WORK -
OWNERS AGENT .�'--• -`� �i rr -/`I�G1''2._ -.,Yl�.r•^S--
�'m-may i Z. SEPTIC TANK,SEEP, PIT(S)
ADDRESS �,/ AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑,
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR;SEWER OR
PLUMBING AND SEWERS. _SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL .OWN & OF THE ABOVE
DESCRIBED RESIDEN �ROPERTY- BACKFILL SEPTIC TANKS❑[-j
SIGNATURE SEEP. PIT(S) CESSPOOLS ��>-,H!
OF PERM ITTE -
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATIOIL_y ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK.
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