HomeMy Public PortalAbout9519 BLACKLEY ST_Sewer__ DEFARTAIENT OF COUNTY ENGINEER } SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
I ADDRESS
FOR APPLICANT TO FILL IN LOCALITY ��µ j�p cjx
BUILDING ��/ `C�'/f _• NEAREST v
ADDRESS -Ki�.l`i�i.-! �+�+C/ CROSS ST.
LOCALITY / DISTRICT N0. SERIAL Nq::7 PERMIT NO.
NEAREST /) S A / O S
CROSS ST. l
RECEIVED BnY4 Ready for Inspection DATE ISSUED
OWNER
MAIL n USEZONE OCCUPANCY MAP
ADDRESS y f/ A _ BK PO �_
CITY ( , TEL.NO. �-�"���A 1
D CONTRACTOR ��+X � , _ CO.IMP.NO.
ADDRESS ' JOB.NO.
V CITY, TELAO. TRUNK PERMIT NO.
STATE
REGISTRATION NO. COUNTY ROAD PERMIT NO. - I
LEGAL STATE ENCROACHMENT I
DESCRIPTION LOT NO. PERMIT NO.
BLOCK TRACT J I INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF NOW ON LOTS O CHARGES
USEOFi
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF (WORK FEE REIMBURSEMENT FEE `\ /
1 HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 3.50 D RECEIPT NO. I �D/►rfE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 /
ALTER OR REPAIR EXISTING NO. DATE \ I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 I STATION J 4• V DEPTH Gi
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 / Cyr 0 MANHOLE�REFERENCE _ LOWER
TYPE OF CONNECTION-1 LENGTH FROM
OWNERS PERMIT 1 00 suR6 ( P L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE d
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
ti
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS f INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER '
SIGNED THIS_..................DAY OF----------------_-.-_................19..._... NEW HOUSE SEWER/J
OWNEROR CONNECT ADDITIONAL
OWNERS AGENT.........................................................................._ BUILDING OR WORK i
SEPTIC TANK,SEEP.PIT(S)
ADDRESS----------•--•-•-------•.... .... ............-........... - - AND/OR DRAINFIELD
CAITHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL I] ORYWELL
ION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER. REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND
DISCONNECT PLUG _
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS I]
SIGNATURE SEEP.PIT(S)El CESSPOOLS
OF PERMITTEE.. ___.-,.__.. .........
-......
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