HomeMy Public PortalAbout9439 BLACKLEY ST_Sewer__ D
CES08 APPLICATION FOR PERMIT
seoe tt-s� COUNTY OF LOS.ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUELDING AND SAFETY DIVISION BUILDING N
JOHN A LAMBIE, County Engmeer ADDRESS
CASSATT D GRIFFIN, Sup t of Buildmg LOCALITY '_� )
FOR APPLICANT TO FILL IN crsoss ST `
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT MAIL rs
ADDRESS t
NO OF BLDGS A
SIZE OF LOT [.D O 0 NOW ON LOT � CITY - 'TEL NO - /
USE OF
BUILDINGS DISTRICT NO GROUP MAP
CONTRACTOR K PG
ADDRESS CONNECTION DATA
CITY EL NO STATION 4=F f _35DEPTH
STATE REGISTRATION NO ® COUNTY MANHOLE REFERENCE r UPPER
LOWER
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO Q
PUBLIC SEWER @ $3 50
SEPTIC TANK SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
ITS AND/OR DRAINFIELD @ $3 00 Y CURB P L M L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00
HOUSE SEWER CONNECTING TO P C NO �7
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO /
87
CONNECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 1 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAC FEE REIMBURSEMENT FEE
1 HAVE AT-THIS DATE A CONTRACT WITH THE HEREIN NAMED CON=
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 1 g NEW HOUSE SEWER
OWNER OR ^--- -- - - - - - -- CONNECT ADDITIONAL-
OWNERS AGENT BUILDING OR WORK •7
ADDRESS '- '- - - - - SEPTIC TANK,SEEP,-PIT(S) -- -- - _
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATIONw�_
AND STATE THAT_THE ABOVE IS-CORRECT-AND AGREE TO COMPLY CESSPOOL[E) DRYWELL[I - - - "
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS ..SEWAGE DISPOSAL SYSTEM- - -- - ---�--
1 -HEREBY CERTIFY THAT"'I-'AM PROPERLY REGISTERED-AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER._OF-,THE ABOVE - - - - -
DESCRIBED RESIDENTIAL PR ERTY _ BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS ❑
OF PERMITTEE
VALIDATION TR08ERT A WObD' �`�
M o C�SH _ SUPERVISING MECHANICAL,ENGINEER ^
1 13R JUL 18 r -- A- -' ---2.00-- "-
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SE 0508 1302210005
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PRONE (626) 285-0488 EXT
(LEGAL ID ISEWER / SEPTIC SEWER BUILDING ADDRESS
ON FILE, (EXIST OCC GRP 9439 BLACKLEY ST I
IBLDGS NOW ON LOT TEMP CA 917803141
(ASSESSOR INFORMATION NUMBER — (CONNECTION TYPE I NEAREST CROSS STREET I
18590-003-002 — (ORIGINATION I ' THOMAS PAGE 596 GRID J4 LOCALITY TEMPLE CITY CAI
I ILENGTH ML TO PL STATION DEPTH
ITENANT IMANHOLE REFERENCE UPPER/LOWER 11SSUED ON PROCESSED BY 1
I 102/21/13 SR
I (COUNTY IMPROVEMENT NUMBER
(OWNER TEL NO IPLAN CHECK NUMBER FINA4 DAT9 BY CODE 1
ITAMANAHA GLENN M,NOREEN M (626) ,287-7660— IJOB NUMBER
19437 BLACKLEY ST (TRUNK PERMIT NUMBER ( `
ITEMP 917803141 IROAD PERMIT NUMBER IDtSCRIPTION OF WORK
I
JAFFADAVIT REPAIR SEWER LINE
IWAIVERNO
1APPLICANT TEL NO (EASEMENT NO 1
IMADDIAN, ARAM (818) 262-3604— 1 I
17949 AJAY DR IRECORD INSTRUMENT NBR RECORD DATE ISPECIAL CONDITIONS
ISUN VALLEY CA 913252 IHIGHWAY/STREET WIDENING
ISTATE ENCROACHMENT PERMIT NUMBER
ICONTRACTOR TEL NO I FEES PAID IAPPftoVALS DATE •INSPECTOR SIGNATURE I
(URGENT ROOTER (818) 587-4368 1 — I TI
17949 AJAY DR LIC NO IFEE DESCRIPTION QUANTITY UOM AMOUNT INEW HOUSE SEWER I I I t
ISUN VALLEY CA 91352 887603 * I I 1 1-1 I '
1 101 PERMIT ISSUANCE FEE 27 80 ICONNECT ADDITIONAL I I
1 115 ALT/REP HOUSE SEWER 1 00 EAC 30 50 (BUILDING OR WORK I I I
(ARCHITECT OR ENGINEER TEL NO I TOTAL FEES 58 30 1 I I
1 I ISEPTIC TANK, SEEPAGE PITI I I
LIC NO
I (AND%'R DRAIN FIELD
I IDRYWELL I I
SEWER MAP BOOK PAGE (ALTER, REPAIR, SEWER OR I
1SEWAGE DISPOSAL SYSTEM
it I I I
IDISCONNECT PLUG AND
(ABANDON HOUSE SEWER
{ I I
IBACKFILL SEPTIC TANKS =I I
ISEEP PIT CESSPOOL
IGRAYWATER SYSTEM I
I I I
I I I I I I
I I I I I I
I i I I I I
I* ADDITIONAL DATA ON FILE
I I I
I I I I I I
IREPORT ID DPR266 ROUTE TO BS0508
I 1 I I I I