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HomeMy Public PortalAbout9429 BLACKLEY ST_Sewer__ 1o.ez 7GA642D APPLICATION ICATION FOR PERMIT 76A84 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A LAMBIE, County Encpneer ADDRESS WILLIAM A JENSEN. Sup t of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST LEGAL D SCRIPT ON LOT NO 0� OWNER MAIL ADDRESS NO OF BLDGS .A SIZE OF LOT NOW ON LOT CI7 TEL NO 1'7' USE OF DISTRICT NK r GROUP MAP PROCESS BY BUILDINGS PG CONTRACTOR ADDRESS CONNECTION DATA CITY TEL STATION DEPTH NO ❑ STATE UPPER REGISTRATION NO ❑ COUNTY MANHOLE REFERENCE LOWER NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO Y CURB PL ML TO P L O PUBLIC SEWER ® 55 00 PC NO U SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO PITS AND/OR DRAINFIELD @ 51000 HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO O PRIVATE DISPOSAL SYSTEM @ 53 00 t� CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE w WORK TO HOUSE SEWER @ $300 a OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE @ SS 00 Z ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING 5 WER OR DISPOSAL EYST 53 O ENCROACHMENT E T NO S IAL WAS EA ROVAL OWNERS PERMIT $ CHARGES AUTHORIZATION TOTAL FEE CONNECTION CHARD E REIMBURSEMENT QO I 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON �f / TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS TO THE PUBLIC SEWER DATE INSPECTOR S 5 NATURE SIGNED THIS DAY OF 19_ r OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK L RESS SEPTIC TANK SEEP PIT(5) HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY H ALL COUNTYORDINANCES AND STATE LAWS REGULATING MBING AND SEWERS CESSPOOL ❑ DRYWELL ❑HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR ENSED AS REQUIRED BY LOS AN COU Y AND STATE SE AGE DISPOSALSYSTEM IFORNIA THAT I A THE NE F AND TEN CONNECT PLUG AND IDE IN T —PC ♦DANDON HOUSESEWER NATURE {{{��� BACKFILL SEPTIC TANKSF PERMITTEE SEEP PIT 15) ❑ CESSPOOLS ❑ VALIDATION ROBERT A WOOD Q2(i7QCK M O CASH SUPERVISING MECHANICAL ENGINEER LL37027w IYR2633 ul 80.004 u 76A64 ,D.ez APPLICATION FOR PERMIT' 78A842D APPLICATION 1 tl COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION AD BUILDING JOHN A LAMBIE, County Engineer '� ? WILLIAM A JENSEN, Sup'1 of Building ALITY i1Z71T REST 1F R APPLICANT TO FILL INSB 5 LEGAL \ DESCRIPT� LOT NO 'I-i MAIL BLOCK TRACT ���/G.jt��. �,�,(J� /f ADDRESS NO OF SLOGS SIZE OF LOT NOW ON LOT CITY TEL NO USE OF DISTRICT NOGROUP MAP PROLES D BY BUILDINGS , BI PG CONTRALTO ADDRESS ` -,� ,�,,r-�j_ CONNECTION DATA C Y TEL NO /v✓ Q r ION `meq Q DEPTH /LJ/ 7 COUNTY MANHOLE REFERENCE/ UPPER REGISTRATION NO ( 4 NO DESCRIPTION OF WORK FEE TYPE OF O CTION LEN H FROM d USE SEWER CONNECTING TO Y P L M L O P L O PUBLIC SEWER @ $500 SEPTIC TANK SEEPAGE PIT OR P O NO V PITS AND/OR DRAINFIELD SIO 00 CO IMP NO JOB NO HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT V PRIVATE DISPOSAL SYSTEM @ $3 00 CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD ITR NO ATE W WORK TO HOUSE SEWER @ $300 CL OVERFLOW SEEPAGE PIT DRAINFIELD N EXTN CESSPOOL DRYWELL MANHOLE @ $500 f 1 Z EPAIR OR AB N N HOUSE HWY OR ST WIDENING SEWER DI O L EM@ $3 00 STATE ENCROACHMENT PERMIT NO /LTJ IND TRIAL WA EAPPROVAL OWNER'SPERMIT $ AUTHORIZA'T'ION TOTAL FEE CONNECTION CHARGE FEE 1 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 SIGH 4' RE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL Y /l 0 BUILDING OR WORK ADDRESS SEPTIC TANK SEEP PIT(S) 1 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 '�' AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR LICENSED AS REQUIRED LOS ANGLES COU�OFY ANP STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT THE L L OWNER Aft INTEND TO DISCONNECTPLUG AND RESIDE IN THE ABO ESCRIB RES[ ENTIA ,PR RTY ABANDON HOUSE SEWER SIGNATURE G �'� BACKFILL SEPTIC TANKS ❑ OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT A WOOD SUPERVISING MECHANICAL ENGINEER CK M OCk CASH �.; 7 0 2 9 u r LI`,R 2 6 1 1 D 2 5.00-- Lo 76A642 0-62 °_f32 7PPLICATION FOR PERMIT 78A 842 TY OF LOS ANGELES SEWER—SEW GE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUDILDING C JOHN A LAMBIE, County Engineer ADRESS WILLIAM A JENSEN, Sup t of Building 1 LOCALITY NEAREST ORP CANT T CRDSB 5T ytlz LEGAL DESCRIPTION LOT N . • OWNER e e MAIL BLOCK TRACE �� ADDRESS NO OF BLDGS L7 SIZE OF LOT NbW ON LOT CITY TEL NO Cf USE OF BUILDINGS / DISTRICT NO GROUP MAP PROCES D BY CONTRALTO ♦F,�� � ��., � ADDRESS �,� _ - CONNECTION DATA +y e7�O �- ION 9 DEPTH J( CI Y (� TEL NO ✓ L! CJ STATE MANHOLE REFERENCE PPER REGISTRATION NO ¢ - ❑ COUNTY a NO DESCRIPTION OF WORK FEE 7y pE F ECTION LENGTH OM 1 O HOUSE SEWER CONNECTING TO ©� Y P L M L TO L V PUBLIC SEWER @ $5 00 PC NO SEPTIC TANK SEEPAGE PIT OR PITS AND/OR DRAINFIELD @ $IO 0 CO IMP NO JOB NO 0 O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT N PRIVATE DISPOSAL SYSTEM @ $3 00 LLLLL�.JJI CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE d WORK TO HOUSE SEWER @ $3 00 Z OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE @ $500 ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT PERMIT NO ) INDUSTRIAL WASTE APPROVAL OWNERS PERMIT 2 00 4 1 4HARGE, AUTHORIZATION TOTAL FEE I p TI FEE 1 HAVE AT THIS DATE A CONTRACT WIT THE HEREIN NA ED CON REIMBURSEMENT FEE TRACTOR TO CONNEC T E ABOVE DES D XISTIN WELLI TO THE PUBLIC APPROVALS DATE I N S P ECTO� G1�N SIAThlr1 RE SIGNED THIS DAY OF �/ 1 OWNER OR i / NEW HOUSE SEWER OWNERS AGENT '�'f�� ' CONNECTADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK SEEP PIT(S) 1 HEREBY ACKNOWLEDGE THAT 1 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 ❑ IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR LICENSED AS REQUIRE BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT M TH LEGAL OWNER OF ND NTEND TO DISCONNECT PLUG AND RESIDE IN THE AB DESC ED SIDEN SAL RITY ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT A WOOD Qv SUPERVISING MECHANICAL ENGINEER CK M O CASH F / L�1o7028% lgtR26 1 0 D 7.00.