HomeMy Public PortalAbout9240 BLACKLEY ST_Sewer__ t:
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S&E683 11 55 APPLICATION FOR PERMIT 1
8&E 8
DIVISION OF'BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS 6-
® CASSATT D GRIFFIN SUP T OF BUILDING FLOCALITYC, I
FOR APPLICANT TO FILL IN C S ST
LEGAL ' OWNER
DESCRIPTION LOT NO
MAIL
BLOCK TRACT �SrF ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY s TEL NO
USE OF / `�� DISTRICTGROUP MAP
BUILDINGS BK PG
CONTRACTO t /Q
ADDRESS f.. CONNEC(TTIION DATA
�� STATION d DEPTH
CITY s.�GJ� � TEL NO
40 MANHOLE REFERENC + UPPER
C3STATE
REGISTRATION NO -• e.► 3"ee i.TY
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF TION LENGTH FROM
PUBLIC SEWER @ $3 SO URB .4=41— M L TO P L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO >
EXTN CESSPOOL,DRYW ELL,MANHOLE Q $2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO /D/h , 40
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT Nb !J 5,440]4"(/
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1 00 no PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
APPROVALS DATE INSPE TOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER 5Cr
SIGNED THIS-1DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AG Nf SEPTIC TANK,SEEP, PIT(S)
ADDRESS ® 43 - 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
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR 1
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF A
ABANDON HOUSE SEWDISCONNECT PLUG AND ER A
CALIFORNIA OR THAT I ANI THE LEGAL OWNER OF THE ABOVE e
DESCRIBED RESIDENT P OPERTY BACKFILL SEPTIC TANKS❑ I
SEEP PIT(S) ❑ CESSPOOLS,-,�l ,vo
SIGNATURE
OF PERMITTEE
JOHN A LAMBIE, COUNTY ENGINE R VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
N 0 CASH
^ /
' COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SE 0508 1302040007
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL ID ISEWER / SEPTIC SEWER BUILDING ADDRESS I
ITR 11492 LT 7 BL C IEXIST OCC GRP 9240 BLAC,KLEY ST
IBLDGS NOW ON LOT I TEMP CA 917803136
ASSESSOR INFORMATION NUMBER ICONNECTION TYPE I NEAREST CROSS STREET ENCINITA
18590-009-008 (ORIGINATION THOMAS PAGE 596 GRID J4 LOCALITY TEMPLE CITY CAI
I (LENGTH ML TO PL STATION DEPTH
ITENANT IMANHOLE REFERENCE UPPER/LOWER (ISSUED ON PROCESSED BY 1
1 102/04/13 SR
(COUNTY IMPROVEMENT NUMBER I1
OWNER TEL NO IPLAN CHECK NUMBER IFINAL DATE FINAL BY CODE 1
IGULLIVER DONALD L TR (626) 285-9246- (JOB NUMBER
19240-BLACKLEY ST (TRUNK PERMIT NUMBER
(TEMP 917803136 (ROAD PERMIT NUMBER - IDESCR PTION OF WORK
I IAFFADAVIT NO (REPLACE 4' INCH SEWER CLAY PIPE WITH 4' INCH TRENCHLESS I
_IWAIVER NO IPIPE IN FRONT PROPERTY (60 FT)
(APPLICANT TEL NO (EASEMENT NO 1
IHERNANDEZ, GENARO (818) 200-3015- 1 1 1
114808 HAGER ST IRECORD INSTRUMENT NBR RECORD DATE ISPECIAL CONDITIONS I
I (HIGHWAY/STREET WIDENING ` r/
I I STATE ENCROACHMENT PERMIT NUMBER �C I J'�
ICONTRACTOR TEL NO I FEES PAID APPR VALS DATE INSPECTOR SIGNATURE
(MIRACLE BUILDER INC (888) 508-6878- 1
14206 W BURBANK BLVD LIC NO IFEE DESCRIPTION QUANTITY UOM AMOUNT INEW HOUSE SEWER 1
BURBANK CA 91505 875657 I I-
1
1 101 PERMIT ISSUANCE FEE 27 80 (CONNECT ADDITIONAL, 1 1
1 115 ALT/REP HOUSE SEWER 1 00 EAC 30 50 1BUILDING OR WORK I 1 1
1ARCHITECT OR ENGINEER TEL NO I TOTAL FEES 58 30 1 1 I I
- I ISEPPIC TANK, SEEPAGE PITI I 1
I LIC NO 1 IAND/OR DRAIN FIELD
I I I
I IDRYWELL I I
I I I
I SEWER MAP BOOK PAGE 1 (ALTER, REPAIR, SEWER OR I 1
I ISEWAGE DISPOSAL SYSTEM
I I I
I IDISCONNECT PLUG AND I I I
I I (ABANDON HOUSE SEWER
I I I
1 IBACKi ILL SEPTIC TANKS =
1 (SEEP PIT CESSPOOL
1 1 1GRAYWATER SYSTEM 1 1 1
I I I I I I
I I I I I I
I I I I I I
I I I I I I
(REPORT ID DPR266 ROUTE TO BS0508 1 1 1