HomeMy Public PortalAbout9477 BLACKLEY ST_Sewer__ 76 -FOR PERMIT 1
SION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
f'/s Deportment of County Engineer
J
County Of LOS Angeles 7ADDRESS
77 .
WM.J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN,SUPT OF BUILDING-FOR APPLICANT, TO FILL IN
LEGAL
,DESCRIPTION LOT No. OWNER 11AC
soe
BLOCK TRACT MAIL Q C
ADDRESS
N0. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY -TEL. NO
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PG
SK
CONTRACTOR. T� @' 4 {I t,% . !� N kr & Q� -
ADDRESS (Ji SL Vg �a.�/ �,!2- CONNECTION DATA
CITY TEL No./�f�+ `� STATION DEPTH
OF / ' ATE MANHOLE REFERENCE + UPPER
_
REGISTRATION N0. eel ❑ COUNTY - /� LOWER
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO - TYPE OF COKNLCTION LENGTH FROM —
PUBLIC SEWER Q $ 3 50 Y CURB P L M L TO P L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG. OR P C NO
WORK TO HOUSE SEWER 1 00 CO IMP N0, JOB NO
ALTER OR REPAIR EXISTING
,ALTER
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 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 200 CHARGES
- CONNECTION CHARGE FEE
OWNERS PERMIT S 1 00
AUTHORIZATION TOTAL FEE ge!� — REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT TIJE ABOVE DESCRIBED EXISTING'DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER -� , Ir
rvEw HOUSE SEWER
SIGNED THIS -DAY OF 19 f
OWNER OR •CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL ElDRYWELL[:1AND 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 -
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF _DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM TH EGAL O 'THE ABOVE ABANDON HOUSE SEWER '
DESCRIBED RESIDENTI L PR R . BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOL'S❑
SIGNATURE _
OF PERMI E
Nalumm
WILLIAM J.F61 COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR c
LACo5 5 5 5 MAY_�1 4 2.00