HomeMy Public PortalAbout9437 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
ADDRESSf!
FOR APPLICANT TO FILL IN, LOCALITY
BUILDING NEAREST
ADDRESS CROSS ST
LOCALITYr DISTR N0. ERI L 0 �P�M 78 c
hpi (71
NEAREST '
CROSS ST, A / J J
"
�, L , RECEIVED BY Ready for Inspection DATEISSUED
avOWNER
MAIL —
ADDRESS 6 USE ZONE OCCUPANCY BK MAP PG
CITY TEL NO
CONTRACTOR1
CO.IMP NO
ADDRESS �i/
JOB.NO 7—
CITY TEL NO TRUNK PERMIT NO
k STATE
REGISTSTION NO `Z r COU TY ROAD PERMIT NO '--
LEGALt 6�1 STATE ENCROACHMENT
DESCRIPTION LOT NO PERMIT NO
BLOCK TRACT R INDUSTRIAL
APPROVAL
NO OF BLDGS
SIZE OF LOT s
NOW ON LOT CHARGES,
US OF
BUILDINGS CONNECTIQNCHARGE FEE /
NO DESCIRIPTION OF WORK FEE \ /
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO � e
PUBLIC SEWER 6 S 350 3 RECEIPT NOTE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL-BLDG OR EXCEP)fION RECORDED
WORK TO HOUSE SEWER 1 00 NO DATE I BY
ALTER OR REPAIR EXISTING r
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER CONNECTION DATA
AND/OR DISPOSAL SYSTEM 1 00
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 1 STATION 1L3 DEPTH 6 /
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200I / DO / MANHOLERREFERENCE ` � /
YV LOWER
TYPE OF CONNECTION LENGTH FROM
y_ eb4tal PL ML TO P L O
OWNERS PERMIT $ I I 00 SEC pC�� J 6, C P
AUTHORIZATION TOTAL FEE I 1� 50
, �'—' � � `�'gOOG�NL�LL-Ed �
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SI NATURE DATE
DWELLING TO THE PUBLIC SEWER �j
SIGNED THIS_ '_ DAY OF_ _ __ .197-
IQ!�- NEW HOUSE SEWER
OWNER OR /may� � _ f, Imo//,^ CONNECT ADDITIONAL
OWNERS AGENT FFP(1���(� n l(��l/(J/(yl , BUILDING OR WORK
ADDRESS_ V t r Q 4 -6- AND/OR DRAINF ELD SEPTIC TANK SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI. CESSPOOL DRYWELL
CAEl
TION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AICD STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOV DE CRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS
SIGNATURE
f SEEP PIT(S)F] CESSPOOLS 0
OF PERMITTEE as�
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