HomeMy Public PortalAbout9232 BLACKLEY ST_Sewer__ Al
76iA 642D-CE808 A-7/76 APPLI C ION FO PERMIT
SEWER— EWAGE D PC
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN DISTRICT NO.1 GROUP I BK MAP Pa CESSED BY
BUILDING /^ /^7 /f� j/�) 3j
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ADDRESS ` �1[, p Y� .P\ "�(/' r /✓
00 1� ` ,1 CONNECTION DATA
LOCALITY TT
NEAREST I" t STATION .�'/) DEPTH
CROSS ST. -N /G
MANHOLE REFERENCE y..L-_S`� �� W'PER
OWNER .'� G
TYPE OF CONNECTION LENGTH FROM
MAIL Y. CURB M.L.TO P.L.
ADDRESS �. 3 .�
P.C.NO.
CITY, C -TEL. NO.'J 4S O ei oq
CO.IMP.NO. JOB NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT WAIVER [ASEN[NT RECORD.INSTR.NO. DATE
BLOCK G TRACT �/ 9
t NO. OF BLDGS.
(J
SIZE OF LOT X��/� NOW ON LOT HWY.OR ST.WIDENING
USE OF STATE ENCROACHMENT
BUILDINGS �q/-
PERMIT NO.
INDUSTRIAL
CONTRACTOR /H- A- r4 (� WASTE APPROVAL
ADDRESS 8CHARGES
!Jt c/V r• b . G
clTr
el 1 U TEL. NO.y Y (� 6 CONNECTION CHARGE FEE
STATEdd f
LICENSE NO:. d� GLASS ` f� REIMBURSEMENT FEE
NO. DESCRIPTION OF WORK FEE APPROVALS DATE ISPE TOR'S SIGNATURE Ly
HOUSE SEWER CONNECTING TO �-
PUBLIC SEWER '�— �/ / '
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECTADDITIONAL c
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM @ SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL Cl DR-YWELL ❑
E XTN.,CESSPOOL.DRYW ELL.MANHOLE
ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR.SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS ❑
OWNER'S Issuance Fee $
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AUTHORIZATION TOTAL FEE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. PLUMBING AND SEWERS.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SEWER. LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF
SIGNED THIS DAY OF iJ_ CALIFORNIA OR T A IA THE L�E G•/� O ER OF, AND INTEND TO
OWNER OR RESIDE IN, THE 'E DESCRI 6 NTIAL PROPERTY.
OWNERS AGENT
SIGNATURE
OF PERMtTT /(
VAL ATIO
CK. M.O. CASH
3 2 1 N;.t,R �y 1 u D `1 8.0 0 os::;