HomeMy Public PortalAbout9520 BLACKLEY ST_Sewer__ '.- D
6&E-663 12.54' APPLICATION ;FOR PERMIT
� 8 Q E•6
DMSION OF BUMDING AND SAFETY SEWER-SEWAGE DISPOSAL
Depostmeat of Cotiaty Engiaeer
1 County of LOS Aagele8 BUILDING
WM.J. FOX. COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN, SUPT OP BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. - !t--
LEGAL
DESCRIPTION LOT N0. (G'i OWNER
BLOCK TRACT 7 -Z, MAIL
ADDRESS
y NO.OF BLDGS.
SIZE OF LOT ♦ /� NOW ON LOT CITY TEL NO
USE OF
BUILDINGS G� ° ""r" DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR �i - r CJ
ADDRESS/ ! CONNECTION DATA
CITY -�//1t� �� TEL. NO. STATION DEPTH
!!! STATE MANHOLE REFERENCE
REGISTRATION NO. l.f, ❑ COUNTY I UPPER LOWER
TYPE OF CONNECTION - LENGTH FROM
NO, I; DESCRIPTION OF WORK FEE Y CURB P.L. M L.TO P L _
.HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 3.50 —�
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. JOB NO.
WORK TO HOUSE SEWER 1 00
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. i
SEPTIC TANK, SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
'SPECIAL CONDITIONS ONLY 200 CHARG
- r
CONNECTION CHARGE FEEZ
OWNER'S PERMIT $ '" 1 00
AUTHORIZATION TOTAL FEE Q REIMBURSEMENT FEE/
TRACTORHAVE T TO CONNE THIS DATE ONTRTHEA ABODVE DESCRIBED EXISTINGTHE HEREIN AMED DWELLING APPROVALS DATA INSRECTOR'S SIGNATURE
TO THE PUBLIC SEWER y
NEW HOUSE SEWER '
SIGNED THIS DAY OF 19—
OWNER OR •CONNECT ADDITIONAL
OWNERS AGENT - BUILDING OR WORK 12 I
SEPTIC TANK,•SEEP, PIT(S) '
ADDRESS - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL[I -
AND STATETHAT 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 PLUGAND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA-OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
>j t� -SEEP.PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTEE
WILLIAM J.-FOX.COUNTY ENGINEF-R- VALIDATION-
- �i- 0 5 ,'M20-3' - 4 2'.0 0 .n
r,,BY BY _ ..
' DEPUTY DEPUTY
BY BY
>-0 DEPUTY .y DEPUTY