HomeMy Public PortalAbout9452 BLACKLEY ST_Sewer__ 7
G&E6 31254 APPLICATION FOR PERMIT ■
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Dep. ent of County Engineer
County of LOS Angeles BUILDING Qj p��rs
WM J. FOX. COUNTY ENGINEER ADDRESS C�7 �i.
—MIMO
CASSATT D GRIFFIN, SUP'T OF BUILDING- -
LOCALITY VVV
FOR APPLICANT TO FILL IN NEAREST
CROSS ST
LEGAL �p
DESCRIPTION LOT NO �] OWNER•j�p�
BLOCK TRACT 2 MAIL
ADDRESS
NO OF BLDGS.
SIZE OF LOT �. �� �',� NOW 0F
LOT CITY TEL NO
USE OF y{,r
BUILDINGS DISTRICT NO GROUP MAP
gyp'(/
1 �, BK PG
CONTRACTOR
ADDRESS 7 CONNECTION DATA
CITY i/ TEL NO �T�� te� P.4 STATION DEPTH
MANHOLE
REFERENCE
REGISTRATION NO i ❑ COUNTY UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE Y CURB P L M L TO P LL
HOUSE SEWER CONNECTING TO .4 Z O / i:96 Y 73
_ PUBLIC SEWER Q $ 3 50 CCCLLL
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG ORg D .gpy�g, NO 7 LZ JOB NO
WORK TO HOUSE SEWER 1 00 V
ALTER OR REPAIR EXISTING
_ SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 200 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ 1 00
AUTHORIZATION TOTAL FEE xv o REIMBURSEMENT FEE
TRACTORHAVE T TO CONNECT THEHIS DATE A ABODVEWDESCR BED EXISTTINGITH THE HEREIN A DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAOF 19- NEW HOUSE SEWER
I CONNECT ADDITIONALOWNER OR t
OWNERS AGENT BUILDING OR WORK `Z Z�I�S�y .v .,�►'
SEPTIC TANK, SEEP, PITS)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL[IAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF D
ABANDON HOUSE SEWER
DISCONNECT PLUG AN
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
4 SEEP.PIT(S) ❑ CESSPOOLS
SIGNATURE b e
OF PERMITTEE
WILLIAM J. FOX.COUNTY ENGINEER VALIDATION
_1O6066� Ja28 4 2.00
BY BY
DEPUTY d� DEPUTY
BY BY
0 DEPUTY DEPUTY