HomeMy Public PortalAbout9456 BLACKLEY ST_Sewer__ 78AB42D ` APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
JOHN A LAMBIE, Coua En ADDRESS
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CAS3ATT D GRIFFIN, Supt of Bvild�ag LOCALITY G �% 1
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
ADDRESS
BLOCK TRACT / S MAIL
r%TiO OF BLDGS /
SIZE OF,LOT NOW ON LOT [ CITY TEL NO
USE OF
DI DIq
ROUP MAP P�A�ESSED BY
BUILDINGS CCC/ /)
CONTRACTO J� ` /,,gee ��/�ADDRESStE�ftZ { JJJ� CONNEs" CTION'DATCITY TELNO , , DEPTH
REGISTRATION NO STATE MANHOLE EFE FiCE UPPER
NO DESCRIPTIO OF WORK FEE LOWER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00
SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3 00 Y C RB P L M L TO P L
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00
HOUSE SEWER CONNECTING TO P
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO NO
CONNECT ADDITIONAL BLDG OR f ('� 'TRUNK-PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1 00
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACH
SEWER OR'DISPOSAL SYSTEM @ $1 00 PERMIT NO
INDUSTRI
WASTE A4rPROVAL
CHARGES
OWNER'S- PERMT $ 2 OD CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE to REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS ' DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER
SIGNED THIS AY OF 19— NEW HOUSE SEWER
OWNER OR CONNECT DDWORKAL -71115,/4
OWNERS AGENTI
ADDRESS SEPTIC TANK SEEP, PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL El DRYWELL[I
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER,OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM P OPERLY REGISTE AND/ DISCONNECT PLUG AND -
LICENSED A EOUIRED BY S G LES NTY D TAT OF ABANDON HOUSE SEWER
CALIF 0 T I H L AL NER E 0
DESCRIB D RESIDEN L 0 R 1 SEEPFPIT(S)P❑C ANKS[I ❑
SIGNATURE
OF PERMITTE _ �
®� ALMATION ROBERT A WOOD
cic m D CASH SUPERVISING MECHANICAL ENGINEER
L.1 O 3 2 3 ouL 13 l7 A J .U'Q M .
76A6APPLICATION(CATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer _
Countyof Los Angeles BUILDING -
JOHN A LAMBIE COUNTY ENGINEER ADDRESS n rk le,
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST U ►�' f
LEGAL /
DESCRIPTION LOT NO OWNER r oMAIL
S
BLOCK TRACT /G` 0 17 Z ADDRESS
NO OF BLDGS CITY TEL NO
SIZE OF LOT� s ',� NOW ON LOT
USE OF
BUILDINGS DISTRICT NO I r + GROUP MAP
BK PG
CONTRACTOR �Q
ADDRESS v CONNECTION DATA
CITY / �TEL'NO � STATION'. � MANHOLE REFERENCE DEPTH UPPER
S T'❑ COUNTY TAT LOWER
REGISTRATION NO
NO DESCRIPTION OF WORK FEE /
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3 50 Y CURB P L M L TOP L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN ,CESSPOOL,DRYWELL,MAN HOLE @ $ 2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $100 TRUNK PERMIT NO D PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $100 J4 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $100 WASTE APPROV
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT S t o0
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CoN- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PITS) y
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL ElDRYWELL❑
AND 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
I 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 I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT L P ERTY BACKFILL SEPTIC TANKS ElSIGNATURE SEEP PITS) [:1'CESSPOOLS❑
OF PERMITTEE fiaj�e4x — t
e
t
JOHN A LAM I . COUNTY ENGINE VALIDATION ROBERT-A WOOD, CHIEF PLBG INSPECTOR
CK EE 0 CASH ,A7r
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