HomeMy Public PortalAbout9314 BLACKLEY ST_Sewer__ -4 F
24650 INSERTS
CEAPPLICATION FOR PERMIT ,
78A642.D 842D COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING '
ADDRESS
JOHN A LAMBIE. County Engineer
WILLIAM A JENSEN. Supt of Building LOCALITY C
NEAREST L(JL,FOR APPLICANT TO FILL IN CROSS ST CGY/
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACTMAIL p
ADDRESS /- x
NO OF BLDGS LC' cl-A
SIZE OF LOT NOW ON LOT CITY ` TEL NO
USE OF ICO GROUP PROCESSED BY MAP
BUILDINGS DISTRT NI '
� � BK �
CONTRACTOR c lo
f
ADDRESS'�,�, ,�,,/te�d,,,�..,,// d ���.�, CONNECTION DATA -
CITY L'G' 'Lat TEL NO Ve— —;?– 7 I STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO ® COUNTY LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO 40
PUBLIC SEWER @ $3 00 TYPE UF C NNECTION LE GTH FROM _
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO - - - - P 0 -
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO OB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO V
WORK TO HOUSE SEWER @ $1 00
SEWER OR DISPOSAL SYSTEM HOUSE @ $i 00 STATE ENCROAC ENT 03
PERMIT NO
INDUST L
WAS APPROVAL W
CHARGES L�
OVT11jER'S PERMIT $ 2 00 CONNECTION CHARGE FEE �y
AUTHORIZATION I TOTAL FEE ) REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE-ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL �09�
OWNERS AGENT BUILDING OR WORK '`
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND _
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED REST R,(
AL Pf�p$E Y BACKFILL SEPTIC TANKS [:IS -
SIGNATURE fSJ,( SEEP PIT(S) ❑ CESSPOOL
OF PERMITT " 5
®r VALIDATION ROBERT A WOOD w
CI: N o Gsx SUPERVISING MECHANICAL ENGINEER
�h,).r_10 5 8 2 zo ,IOL 26 1 0 0 3 .0 0 �^