HomeMy Public PortalAbout9222 BLACKLEY ST_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
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COUNTY OF LOS ANGELES I BUILDING �J'�d
WILLIAM J. FOX, COUNTY ENGINEER ADDRESS / L /+ U
FOR APPLICANT TO FILL IN LOCALITY U
BUILDINGNEAREST
ADDRESS CROSS ST g
LOCALITY DISTRICT NO SERIAL NO PERMIT NO
NEAREST
A - 2'7 S
CROSS ST
RECEIVED BY Ready for Inspection DATEISSUED
�_
OWNER _ / L_S-tl-
MAILAD RESS L ' USE ZONE I OCCUPANCY I BK MAP PG
CITY ` TEL NO. 7Q�/_ `/ 1,•J\���
CONTRACTOR CO IMP NO
ADDRESS �� JOB NO
CITY ��� -TEL NO ��� ���� TRUNK PERMIT NO
REGISTRATION NO 3G /3- &- 4�1 -.S1 1
ROAD PERMIT NO
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. rT PERMIT NO
BLOCK TRACT ,/�7 INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO OF NOW ON LOTS CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 350 RECEIPT NO (DATE IBY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR EXCEPTION RECORDED
WORT(TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING NO I DATE IBY
_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/ORDRAINF1ELD 200 STATION 9f +� DEPTH la
CESSPOOL—DRYWELL
SPECIALCONDITIONS ONLY 200Go( '�j MANHOLERREFERENCELj LOWER
TYPE OF CONNECTION LENGTH FROM�I_.[
OWNERS PERMIT ; 1 00-1 CURBS P-lAy M L TO P L /ys�
AUTHORIZATION I TOTAL FEE
1, 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 (
SIGNED THIS_ _ .___ DAY OF ___ 19 __ NEW HOUSE SEWER
OWNER OR �� D CONNECT ADDITIONAL
OWNERS AGENT � �'`- -. _ _ __ _ BUILDING OR WORK
T SEPTIC TANK,SEEP.PIT(S)
ADDRESS - - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI-r CESSPOOL 0 DRYWELL
CATION 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 AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS E]SEEP PIT(S)❑ CESSPOOLS
SIGNATURE �G t� O� ` •�aS
OF PERMITTEE
76A642A 663 7/53 D� +