HomeMy Public PortalAbout9405 BLACKLEY ST_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS �y
CASSATT D GRIFFIN, SUPT OF BUILDING 1 f<�
FOR APPLICANT-TO FILL I LOCALITY ^� f�
BUILDING � j / J �I NEAREST
ADDRESS /� / C�X�C / CROSS ST
DISTRICT NO 4 SERIAL NO PERMIT NO
LOCALITY S
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NEAREST
CROSS ST
RECEIVED BY , Ready for Inspection DATE ISSUED
' OWNER �-ll� E_ _ E ' i3
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MAIL ,
• ADDRESS j , USE/ZONE OCCUPANCY AP
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CITY TEL NO Q �'lll
CONTRACTOR CHARGES REIMBURSEMENT FEE
ADDRESS REQUIRED
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3��J NOT REQUIRED
CITY / TEL NO XTE JOB NO f �•/p P� CONNECTION CHARGE FEE
REGISTRATION NO [ ST901lIPt•T� CO IMP NO Il %4 7 (� t1 L' 11
LEGAL RECEIPT NO I DATE I BY
DESCRIPTION LOT NO
BDCK�).,() OfTRACT/1�13-s/DA/ ' �C-7.t/ /P��S' WAIVER FOR RECORDING
r NO OF BLDGS
SIZE OF LOTS_v�/�� NOW ON LOT L RECEIPT NO I DATE �zIrBY
BUI DIUSE NGS We_
e_I j / �-�f„ 'I i — --
NO DESCRIPTION OF WORK FEE TRUNK PERMIT-NO
PHOUSE SEWER UBLIC SEWERCONNECTINO TO 3 50 ROAD PERMIT N0-
HOUSE SEWER CONNECTING TO STATE ENCROACHMENT
PRIVATE DISPOSAL SYSTEM 1 00 PERMIT NO
CONNECT ADDITIONAL BLDG OR INDUSTRIAL
WORK TO HOUSE SEWER 100 WASTE APPROVAL
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
DISCONNECT AND ABANDON SEWER ,y
AND/OR DISPOSAL SYSTEM 1 00 STATION /-� (� DEPTH
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 200 MANHOLE REFERENCE ��/
SPEC ALCONDITIONS ONLY 200 I� -"P,&R ��LOWE 0 /
TYPE OF CONNECTION LENGTH FROM _ v
Y ICURB----PL ML TOPL
OWNERS PERMIT 4HER
00
AUTHORIZATION I TOTAL FEEin
I HAVE THIS DATE CONTRACTED WITH TAMED
HAVE
TO CONNECT THE ABOVE DESCRIBED EXISTING , APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS �' DAY OF 19 ✓ NEW HOUSE SEWER CO2, ,
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS �Y AND/OR DRA;NFIELD IT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI-� CESSPOOL❑ DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIR SEWER
REGULATING PLUMBING AND SEWERS SEWAGE-DISPOSAL SYSTEM
I HEREBY C FY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LIC__ ED AS REQUIRED BY LOS ANGELES COUNTYABANDON HOUSE SEWER
AND STATE F C IFORNIA OR THAT I AM THE LEGAL OWN-
ER OF TAH
ABO DER BED RE ENTIAL PROPERTY BACKFILL SEPTIC TANKS I]
SEEP PIT(S)[:] CESSPOOLS
SIGNATURE
OF PERMIT
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