HomeMy Public PortalAbout9523 BLACKLEY ST_Sewer__ � I
24650.INSERTS - •
`6A6421D 0.
�eAea?o APPLICATION, FOR PERMIT � ,
, COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 7",NEAREST
-
JOHN A. LAMBIE. County Engineer'
WLLLIAM A. JENSEN, Supt of Building
FOR APPLICANT TO FILL IN LEGAL
DESCRIPTION LOT NO.
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS: J ZPROC9SSED
SIZE OF-LOT NOW ON LOT ! -CITY EL NO.
USE OF DISTRICT NO. GROUP MAPBY
BUILDINGS -
` BK PG
CONTRACTOR
ADDRESS C NNECTION DATA - r
1101,
CITY TEL NO. 'STATION DEPTH
J {� ATE MANHOLE REFER C UPPER
REGISTRATION NO /� „(,� ?02COUNTY LOWER
NO DESCRIP F WORK FEE q
HOUSE SEWER CONNECTING TO / r-zoG
PUBLIC SEWER @ $3 00 TYPE OF C6NNECTION LENGTH FROM '
PETS AND/ORTANK,
D AINFEEPAGELDT OR @ $3 00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD ,
EXTN CESSPOOL DRYWELL @ S2 00 ,
HOUSE SEWER CONNECTING TO I - P.C.NO,.,-
PRIVATE
O PRIVATE DISPOSAL SYSTEM @ $100 CO IMPN0. jopyLr
N
CONNECT ADDITIONAL BLDG OR ,^ TRUNK PERMIT N0. ROAD PERMIT N0. Q
WORK TO HOUSE SEWER @.41 00 V
ALTER,
OR DISPOSAL ABANDON-HOUSE
HOUSE @ $1 00 STATE ENCROACHME P4
PERMIT NO p
INDUSTRIALO'
WASTE AB^OVAL
P.
CHARGES rp
r
OWNER'S PERMIT i 2 00 CONNECTION C ARG EE
AUTHORIZATION I TOTAL FEE REIM SE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED'CO
TRACTOR TO C90NNECj THE ABOVE DESCRIBE)_" , APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC S '
SIGNED THIS Y OF 19a NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT, BUILDING OR WORK /f /
ADDRESS - �- SEPTIC TANK,SEEP.PIT(S) -
AND/OR DRAINFIELD
'HEREBY ACKNOWLEDGE THAT I HAVE READ HIS APPLICATIONAND STATE THAT THE ABOVE IS CORRECT-AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ _
WITH ALL COUNTY ORDINANCES AND STATE•LAWS REGULATING ALTER,REPAIR,SEWER OR -
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I 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 THATI AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPE BACKFILL SEPTIC TANKS ❑ t
SIGNATURE t SEEP PIT(S).[] CESSPOOLS ❑ _ _
OF PERMITTEE - + J
eF /• I VALIDATION ROBERT A."WOOD
c14 m.o: CASH SUPERVISING MECHANICAL ENGINEER
OCT 1.7 1 C 3.00 _ !P.