HomeMy Public PortalAbout9434 BLACKLEY ST_Sewer__ C �
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76A APPLICATION FO PERMIT
6A642D 642 �J
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE, County Engineer ADDRESS K
WILLIAM A JENSEN Sup t of Building
LOCAL.TY
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T
LEGAL
DESCRIPTION LOT NOpzt
OWNER
i MAIL
2,
BLOCK TRACT �.� � ADDRESS � -
i NO OF SLOGS
SIZE OF LOT I 'r NOW ON LOT CITY L NO
USE OF
BUILDINGS . !� DISTRICT NO OUP MAP OC ESS ED BY
� BK PG
CONTRACTOR � �V /✓ �
RESS l CO ECTION DATA
1 f r
CI N
STATION DEPTH
� L O
STATE UPPER
REGISTRATION O r_ COUNTY MANHOLE REFERENCE LOWER
NO GESC TION OF WOR FEE TYPE CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TOY B P L M L TO P L AF fir, d
PUBA.
LIC SEWER $5 00
SEPTIC TANK SEEPAGE PIT OR la 743 Y, PDS
C NO O
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO .108 NO U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO im
PRIVATE DISPOSAL SYSTEM @ $3 00 0
CONNECT ADDITIONAL BLDG OR /q�/'O AFFIDAVIT WAIY[R EASEMENT RECORD INSTR DATE VU
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD W
EXTN CESSPOOL DRYWELL MANHOLE @ S500 d
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION TOTAL FEE CONNECTION ARGE 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 SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL /
BUILDING OR WORK 1lL�
ADDRESS SEPTICTANKSEEP PIT(S) /
I HFREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 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
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL O ER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBf,�F.�51 TIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE ❑
OF PERMI E BACKFILL SEPTIC TANKS
SEEP PIT(5) ❑ CESSPOOLS Or
VALIDATION ROBERT A WOOD
CK M o C CASH/ SUPERVISING MECHANICAL ENGINEER
Lj1t02 6 1 7%'Q*' AUG 14 1 o D 5.00-
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