HomeMy Public PortalAbout9465 BLACKLEY ST_Sewer__ r
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CE808880 APPLICATION FOR PERMIT,
78A842D COUNTY OF LOS ANGELES
_ SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
ADDRESS If elgtjC"
OHN A LAMBIE, County Engineer
ILLIAM A. JENSEN, Sup t of Bmlc1mg LOCALITY [ '
NEAREST /
FOR APPLICANT TO FILL IN ceoss sr
LEGAL
DESCRIPTION LOT NO 41 fss,dm 11,rie,acres OWNER _
BLOCK TRACT MAIL -
ADDRESS
SIZE OF LOT / D 1-70 NO OF BL
DGS NOW ON LOT
'CITY klTEL NO
USE OF
BUILDINGS DISTRICT NO GROUP P��/yyy PROCESSED BY
CONTRACTOR�r .
ADDRESS J ,e CONNECTION DATA
CITY TEL NO S STATION DEPTH
i
STATEMANHOLE REFERENCE - - UPPER
REGISTRATION NO COUNTY LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CONNECT( N EN T WYROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00 -
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO R PERMIT NO V
WORK TO HOUSE SEWER @ $1 00
SEWER OR DISPOSAL SYSTEM HOUSE @ $i 00 STATE ENCROACHMENT 94
PERMIT NO O
INDUSTRIAL
-_
WASTE APP L 444x777
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE ..
CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBEDEXIISTINGDATE A CONTRACT WITH THE HEREINAMED DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWE ,_
SIGNED THIS DAY. OF. 19�-�-F NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK -
ADDRESS a SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HA(E READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ '
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR i
PLUMBING ANDS SEWERS SEWAGE DISPOSAL SYSTEM `
1 HEREBY CERTIFY THAT 1 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 OWNERJF THE ABOVE
DESCRIBED RESIDEN IA PROP E T BACKFILL SEPTIC TANKS ❑
SIGNATURE ! SEEP PIT(S) ❑ CESSPOOLS
OF PERMITTEE
®rI A
I VALIDATION ROBERT A WOOD
CK to o, CASH SUPERVISING MECHANICAL ENGINEER
LAUD 5�1 0 3 "o "kpR i. 0 t l p 3 .0 G
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7APPLICATION FOR P RIV11T
78A 84
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN 7 CRD55 ST
LEGAL
DESCRIPTION LOT NO OWNER
�I, 1
MAIL
BLOCK TRACT c mtJ� IPS CYP ADDRESS
71? )/�jNO OF BLDGS
SIZE OF LOT/20 NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP OC SED BY
BK PG
CONTRACTOR
ADDRESS 3l P CONNECTION DATA
CITY TEL NO / STATION DEPTH
04
Ll /STATE UPPER
REGISTRATION NO ❑ COUNTY MANHOLE REFERENCE LOWER Jvv a
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM O
HOUSE SEWER CONNECTING TO Y CURB ft PLA_ M L TO P L V
PUBLIC SEWER @ $5 00 �C NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JO O O
PITS AND/OR DRAINFIELD @ $1000 0
HOUSE SEWER CONNECTING TO TRUN ERMI RO RMIT O
PRIVATE DISPOSAL SYSTEM @ $300 f
CONNECT ADDITIONAL BLDG OR AF WAIVE NT INST DATE n'
WORK TO HOUSE SEWER S3 00 N
Z
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSEHWY OR ST NG
SEWER OR DISPOSAL SYSTEM @ $300 02
STATE E OACHM
PERMIT NO
INDUSTRIAL
OWNERS PERMIT
_ WASTE APPROVAL
CHARGES
S i 00
AUTHORIZATION I TOTAL FEE 2
60 CONNECTION CHAR FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
To THE PUBLICSEW R APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS D Y F C114v196$
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ IS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND GREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CESSPOOL ❑ DRYWELL ❑
PLUMBING AND SEWERS ,.f
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER $F� SEWER OW
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SE,�MiO£:DF$PO$A1,dSYST1t ph 9A_
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND r
RESIDE IN THE AB E DE IjIED RESIDENTIAL P�ERTY ABANDON HOUSE SEWER
SIGNATURE U BACKFILL SEPTIC TANKS ❑
OF PERMIT SEEP PIT(S) ❑ CESSPOOLS ❑
ALIDATIO' ROBERT A WOOD
CK M o �CA � SUPERVISING MECHANICAL ENGINEER
LItLo 7 2 3 6.:� UdL 8 1 0 G fj,l. 0-