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HomeMy Public PortalAbout9421 BLACKLEY ST_Sewer__ TMLE CITY 10-63 76A642D APPLICATION FOR PERMIT 6A64 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING 'I JOHN A LAMBIE, County Engineer ADDRESS 2l E• Blackley WILLIAM A JENSEN Sup t o4 Building LOCALITY TempleCity NEAREST Cloverl [7BLOCK R APPLICANT TO FILL IN CROSS 9T �J AL LOT NO /\, OWNER Robt�•1 MDSmnith TRACT .^�) Jz, /5 D ADDRESS m 9421 E. Blackley SIZE OF LOT (/ NOWOON LOTS CITY Tem le Cit yTEL NO USE OF ©b DISTRICT NO GROUP MAP ;PROCESSE BY BUILDINGS GC 0 f BK PG/^/ CONTRACTORSewer Se vice {.f ADDRESS Rd. CONNECTION DATA CITY 1 Monte TELL NO I.J.-2020 STATION , DEPTH REGISTRATION NO 1270 H COUNTY S TATE MANHOLE REFERENCE UPPER 4::n 400011h. NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FR M HOUSE SEWER CONNECTING TO O Y CURB PL ML TO P L PUBLIC SEWER @ $5 00 P C NO SEPTIC TANK SEEPAGE PIT OR CO IMP NO .108 NO r O PITS AND/OR DRAINFIELD S1000 V HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO p[ PRIVATE DISPOSAL SYSTEM @ $3 00 0 CONNECT ADDITIONAL BLDG OR AFFIDAVIT YI AIVIR IAIIMINT RECORD INSTR NO 6ATE WORK TO HOUSE SEWER @ S300 OVERFLOW SEEPAGE PIT DRAINFIELD l!J EXTN CESSPOOL DRYWELL MANHOLE @ $500 d ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING N SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL OWNERS PERMIT $ z 00 CHARGES AUTHORIZATION I TOTAL FEE 1 7 100 CONNECTION CHARGE FEErrr777 /�� n/ 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE / , y TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING / fJ (J TO THE PUBLIC SEWER APPROVALS DATE INSPECT R S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK SEEP PIT(S) I HEREBY 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 REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNE OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE ABOVE DES RIBED RESIDEN AL P PERTY ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑ LIDATION ROBERT A WOOD SUPERVISING MECHANICAL ENGINEER CK M O CASH LAAO 3 1 7 0—,c; JUN 2 9 a 2 D 18 6.2 S -•� LAL,0 3 1 7 2 JUN 2 9 1 0 D 7.0 0- 6A64 ,2D 7 0-63 APPLICATION FOR PERMI 6A64u COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FNEAREST G9421 B1aCkI® S + JOHN A LAMBIE, County Engineer S WILLIAM A JENSEN Supt of Building 0mpla City Y Alessandro Ave. LEGAL FOR APPLI,jCANT TO FILL IN 7 BT DESCRIIPTION P©n.T NL©y OWNER Robert M. Smith * MAIL R421 Blackley S't BLOCK 1y[} TRACT 1`ia9sio�. View Acres ADDRESS '] /5.�.(. .{}I� SIZE OF LOT /Oe6 �l..V- NO WOON LOTS 2 CITY Temple Git TEL NO 2O(_ 674 USE OF Single residence y_ g� o DISTRICT NO JGROUP MAP PROCE ED BY BUILDINGS 1�y 11 OG nn BK PG f CONTRACTOR �V ADDRESS CON_NEGZIQN DATA STATION DEPTH CITY TEL I}�y STATE MANHOLE REFER CE UPPER REGISTRATION NO LJ COUNTY LOWER NO DESCRIPTION OF WORK FEE TYPE OF CNNECTION LENGTH ROM HOUSE SEWER CONNECTING TO Y URB PL M L TO P PUBLIC SEWER @ $3 00 PC CO IMP NO NO d SEPTIC TANK SEEPAGE PIT OR JOB NO O PITS AND/OR DRAINFIELD @ SIO00 V HOUSE SEWER CONNECTING TO TRUNK PE IT NO ROAD PERMIT NO PRIVATE DISPOSAL SYSTEM ® $3 00 `w CONNECT ADDITIONAL BLDG OR AFFIDAVI wl,ll rAs[Mexi RECORD INSTR NO DATE O WORK TO HOUSE SEWER a $300 OVERFLOW SEEPAGE PIT DRAINFIELD l!J EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 p, At+E-R--REP7TTR'9R ABA N DON HOUSE HWY R ST WIDENING h STE A $300 STA ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT S 2 00 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 APPROVALS TO THE PUBLIC SEWER DATE INSPECTOR S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK SEEP PIT(S) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL 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 LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INJEND TO DISCONNECT PLUG AND RESIDE IN THE ABOVE DESCRIBED RESIDE NTI PROPERTY ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ OF PERM�TEE SEEP PIT(S) ❑ CESSPOOLS ❑ OVALIDATION ROBERT A WOOD cK m o CASH SUPERVISING MECHANICAL ENGINEER LA 156'0- 3 05- GGT 14 1 0 D 5.0 0