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Home My Public Portal About9306 BLACKLEY ST_Sewer__ 76A642o64 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A LAMBIE, County Engineer ADDRESS 1 WILLIAM A JENSEN, Sup't of Building .yam+ Locnurr NEAREST FOR APPLICANT TO FILL IN `ROSS ST LEGAL / DESCRIPTION LOT NO OWNER f) MAIL BLOCK TRACTC� ADDRESS j NO OF BLDGB SIZE OF LOT NOW ON LOT CITY USE OF DISTRICT NO GROUP MAP PROCESSED BY BUILDINGS [/gam — CONTRACTO Z L-5 . V / //j/� ADDRESS U CONNECTION DATA (� `s CI TEL NO 4 STATION rOA 1 DEPTH STATE REGISTRATION NO z zY ® COUNTY MANHOLE REFERENCE %/ C LOWER NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION V LENGTH FROKJ HOUSE SEWER CONNECTING TO Y PL ML TOPIL PUBLIC SEWER @ $5 00 [7V C NO SEPTIC TANK SEEPAGE PIT OR JOB NO } PITS AND/OR DRAINFIELD @ $1000 CO IMP NO D_ HO US .b G E SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO -3/9PZ/ U PRIVATE DISPOSAL SYSTEM $300 CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE OC WORK TO HOUSE SEWER @ $300 Q ,- OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 U ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING LJJ D. SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT U) PERMIT NO Z INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT s z o0 AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER APPROVALS D TE INSfECTOR4 SIGNATURE SIGNED THIS DAY F / 19_ OWNER OR / NEW HOUSE SEWER 2w OWNERS AGENT „LSI ��L CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK SEEP PIT(S) I D HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR RAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ 1HEREBY CERTIFY THAT I AM PROPERLY EGISTERED AND/OR ALTER REPAIR SEWER OR LICENSEDAS REQUIRED BY LOS ANGLES COU TY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNE OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE A90V ESGRIB REST E AL PROPERTY ABANDON HOUSE SEWER SIGNATURE OF PERMI �.� BACKFILL SEPTIC TANKS ❑ SEEP PIT(e) ❑ CESSPOOLS ❑ VALIDATION ROBERT A WOOD CK M O SUPERVISING MECHANICAL ENGINEER CASH _ 1 ce LHI,o 5 1 0 9 JUN 19 1 0 p 7.00- 5 CEftoa 3-64 - APPLICATIO FOR PE IT �aAeaa� �[ COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL fLll DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A LAMBIE, County Engmeer ADDRESS WILLIAM A JENSEN, Sup t of Buildmg LOCALITY NEAREST FOR APPLICANT TO FILL IN CROS6 S7 LEGAL DESCRIPTION LOT NO OWNER MAIL BLOCK TRACT ADD SS eg"-O O OF BLDGS SIZE OF LOT OW ON 6.4T / CITf, EL NO USE OF r BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY PG CONTRACTOR � V� V � ADDRESS m CONNECTION DAT e CITY NO STATION DEPTH STATE UPPER MANHOLE REFERENCE LOWER REGISTRATION NO COUNTY NO GES CRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO Y CURB PL M L TOP L PUBLIC SEWER $5 00 SEPTIC TANK SEEPAGE PIT OR J C NO }, PITS ANDIOR DRAINFIELD @ 51000 CO IMP NO JOB NO O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO U PRIVATE DISPOSAL SYSTEM @ $300 CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIVEN EASEMENT RECORD INSTR NO DATE Im 0 WORK TO HOUSE SEWER @ S300 O OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE @ 5500 �4JJ ALTER REPAIR O OUSE HWY OR ST WIDENING SEWER OR OSH' Q @ $300 & STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT S 2 Oo CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE I �.S ) I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON R IMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEW APPROVALS DATE INSPECTOR S SIGNATURE SIGNED THIS AY OF OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK SEEP PIT(S) I HEREB ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I M TH LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE ABO DES BED RESIDENTI L PROPER ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT A WOOD CK M O CASH SUPERVISING MECHANICAL ENGINEER L �4 3 8 3 AN23 1 0 D -5.00- 7