HomeMy Public PortalAbout9342 BLACKLEY ST_Sewer__ D
CESOB- APPLICATION R PERMIT
Eeoe•e•ss COUNTY OF LOS ANGELES SEWER-SEWAGE
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engineer 00,
CASSATT D. GRIFFIN, Sup't of Building LOCALITY ;�Ce (:3
NEAREST el
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT NO
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL.NO.
USE OF
BUILDINGS _ DISTRICT N0. GROUP MAP PROCESSED BY
BK P6
CONTRACTOR
�• r 2
ADDRESS �' ,� / CONNECTION DATA
CITY`�� s L. NO. / e STATION �/D T
/ frTATE MANHOLE REN EQ i UPPER
REGISTRATION NO. (� d� ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION ('LEN H'
J 0
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. M.L." 01,P:L.r.��
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 .
HOUSE SEWER CONNECTING TO n P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 ? CO.IMP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. %
SEWER ORO R ABANDON SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
IS
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OVNEWS° PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE A REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER
SIGNED THIS AY 19_ NEW HOUSE SEWER �.
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S) /
ADDRESS - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES UNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT THE LEGA NER OF THE ABOVE
DESCRIBED RESIDE N P OPERTY. ACKFILL SEPTIC TANKS❑
SEEP.PIT(S) ❑ CESSPOOLS
SIGNATURE
OF PERMITTE
®F VALIDATION ROBERT A.WOOD
CK. H.o. (CASH SUPERVISING MECHANICAL ENGINEER
L 3 .00 17
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