HomeMy Public PortalAbout9327 BLACKLEY ST_Sewer__ &7SA64
E-6D63 11.55
9 APPLICATION FOR PERMIT 1\
B •6
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles
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��JOHN A. LAMBIE, COUNTY ENGINEER® CASSATT D. GRIFFIN;SUPT OF BUILDINGCALITY
FOR APPLICANT TO FILL IN
NEAREST T. l�
lei
LEGAL OWNER
DESCRIPTION LOT N0.
., .. i MAIL
BLOCKI!;jtj TRACT ��dd � ADDRESS .
NO. OF BLDGS.
SIZE OF LOT � NOW ON LOT CITY TEL. NO.
USE 0� _
.d"'? •,� DISTRICT.N0. I GROUPBK MAP PG
BUILDINGS i.
_ '7_
CONTRACTOR
CONNECTION DATA
9 ADDRESS_ � � j
1. CI /.1 EL. NO. STATION DEPTH
r MANHOLE REFERENCE C �a6 UPPER
/ (2STATE
REGISTRATION N0. 6/'JO ❑ COUNTY '
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO r® TYPE OFC CTION LENGTH FROM
f Y.PUBLIC SEWER @ $3.50 / ^� CUR P.L. M.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR r:
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. N0.
EXTN.,CESSPOOL,DRYWE LL,M AN HO LE @ $ 2.00 CO. IMP. NO. � � JOB NO.HOUSE SEER
�p
PRIVATE DISPOSAL SYSTEMG TO @ $1.00
TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
^� CONNECTION CHARGE FEE
OWNER'S PERMIT S 1 00
AUTHORIZATION TOTAL FEE A REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE [ SPECTOR•SSIGNATURE
-
TRACTOR TO CONNECT THE ABOVE DESCR D EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 ai/ CONNECT ADDITIONAL
OWNER OR / BUILDING OR WORK _
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS
AND/OR DRAINFIELD
I, HEREBY ACKNLEDGE T AT I HAVE READ THIS PLICATION 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
1 HEREBY CERTIFY THAT 1 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 M THE LEGAL OWNER F THE ABOVE
DESCRIBED RES IDENTI PERTY./ Bk ! SEPTIC TAN KS.// '� 'SEEP. PIT(S) �ESSPOOLS❑ ' 1
SIGNATURE
OF PERMITTEE �•' L
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A. WOOD. CHIEF PLBG. INSPECTOR
CK. M.0. CASH /,