HomeMy Public PortalAbout9338 BLACKLEY ST_Sewer__ 7 71! 6 F 6/ 77
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76A642D APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS /J e
WILLIAM A JENSEN, Sup t of Building LOCALITY e/fJ („^
It
NEAREST Q
FOR APPLICANT TO FILL IN `ROSS 5T C
LEGAL
DESCRIPTION LOT NO (' OWNER
MAIL
BLOCK TRACT • • ..✓ �+ ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
KPG
CONTRACTOR /y
. lJ� G lOC 7z
ADDRESS / CONNECTION DATA
t STATION 7 DEPTH
- '!
CITY ] TEL NO � {0
TATE //' PP R
REGISTRATION NO ZdKO COUNTY MANHOLE REFERENCE -�I �
NO DESCRIPTION OF WORK FEE TYPE OF CO TION a LENGTH FROM
HOUSE SEWER CONNECTING TO Y URB P L M L TO P L
PUBLIC SEWER @ S5 00
SEPTIC TANK SEEPAGE PIT OR P C NO a
PITS AND/OR DRAINFIELD @ SIO 00 CO IMP NO J"�V .108 NO O
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ 33 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EA6I.EtiT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ 53 00
OVERFLOW SEEPAGE PIT DRAINFIELD L1J
EXTN CESSPOOL DRYWELL MANHOLE @ 5500 a
ALTER REPAIR OR ABANDON HOUSEHWY OR ST WIDENING N
SEWER OR DISPOSAL SYSTEM @ S3 00 STATE ENCROACHMENT Z
/
7J-
f 144 7 PERMITNO
�f INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT S 2 Oo
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 DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER Q
OWNERS AGENT
CONNECT ADDITIONAL �j/� /• ���
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PITS)
IHFREBY 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 ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND WATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OFD TEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOV SCRIBE SI DENTIAL P RT
Y ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A wooer
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
L&01 9 4 7 MAY 1 1 1 0 D 5.00—
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