HomeMy Public PortalAbout9217 BLACKLEY ST_Sewer__ DEPAIVIP ENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY. PERMIT APPLICATION
COUNTY OF LOS ANGELES
BUILD NG WILLIAM J. FOX, COUNTY ENGINEER r
ADDRESS
FOR APPLICANT TO FILL IN �^/ � LOCALITY
BUILDING 1 `t NEAREST v
ADDRESS CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST
,5 A 70.3& s
CROSS ST.
' RE•EIVED BYn Ready for Inspection DATEISSUED
OWNER j/nom [/Q 9
MAIL ^ USE ZONE OCCUPANCY BK M/FP PG
ADDRESS .�C�% ,
CITY TEL.NO. > L —14
CONTRACTOR
CO.IMP.N0.
ADDRESS �224 !OB NO.
CITY 1' L.NO �jo S ,a TRUNK PERMIT NO.
REGISTRATION N0. 4 COUNTY ROAD PERMIT NO. 76
LEGAL y STATE ENCROACHMENT //
DESCRIPTION LOT N0. (J /;eC PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOTS e NO.OF BLDGS. CHARGES
?11 i 4; NOW ON LOT
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRI TION OF WORK FEE /'
HOUSE SEWER CONNECTING TO �. REIMBURSEMENT FEE /
PUBLICSEWER @ $ 3.50 17 •� is RECEIPT NO. I DA I BY
HOUSE SEWER CONNECTING TO 00,
_ PRIVATE DISPOSAL SYSTEM 1.00
/ CONNECT ADDITIONAL BLDG,.OR /� EXCEPTION RECORDED
/ WORK TO HOUSE SEWER 1.00 (/
ALTER OR REPAIR EXISTING NU. I DATE �� BY
SEWER OR DISPOSAL SYSTEM 1.00 '
-, DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA +
SEPTIC TANK,SEEPAGE PIT OR �+
PITS AND/OR DRAINFIELD 2.00 STATION �'.8�u�i DEPTH
CESSPOOL—DRYWELL ��
SPECIAL CONDITIONS ONLY 2.00MANHO LE PER REFERENCE
UPTYPE OF CONNECTION LENGTH FROM g g
-Y-1- CURB _ej— M.L.TO P.L. S c5
OWNERS PERMIT g a�, L
/._�` �
AUTHORIZATION TOTAL FEE V
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC-SEWER�y J �,j ,a;,............. 19.a?�f NEW HOUSE SEWER
SIGNED THIS.-.--.. P___..-_DAY or..... e. _:....—.., _
OWNER OR . �• " p AL
OWNERS AGENT: .__._l_.G ._ f ��.tPa' BUILDING ORDWORK '-/r/�eeY1PAi� fa ✓F3
r
SEPTIC TANK.SEEP.PIT(S)
ADDRESS...9 �_. !� �'.:_ !!!:p �f`�Y '{ AND/ORDRAINFIELD
1 HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLI= CESSPOOL E] DRYWELL ElCATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY.WITH.ALL-COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR ;
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY. CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED`'4S REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORN'IA'OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
C�
SEEP.PIT(S)E] CESSPOOLS c� e��,` 13%,
•SIG NATURE•
'"OF PERMITTEE ..___._ _.._ ._ _
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