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HomeMy Public PortalAbout9535 BLACKLEY ST_Sewer__ =/f 76A 642D -CEBOB-10-71 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 4DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ADDRESS LOCALITY -"DESNEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL MAIL CRIPTION LOT NO. •OWNER �� (C^���',//LL/ BLOCK TRACT ADDRESS ` V(f 'lI NO. OF BLDGS. //f' �,,n SIZE OF LOT NOW ON LOT CITY (�LPL. TEL. NO. USE OF DISTR(CT NO.1 GROUP _ MAP PROCESSED BY BUILDINGS i BK PS CONTRACTOR ✓y(,/ l ADDRESS '' CONNECTION ATA CITY �' TEL. NO. �"�.�•� 1 ON DEPTH STAT /)J LIC r MANHOLE REFERENCE LICENSE NO. 4/ CLASS ' LOWER .. NO. .DESC IPT'ON F WORK FEE T E OF CO NEG O LENGT FROM 3 o / HOUSE SEWER CONNECTING TO Y. UR M.L.TO P.L. PUBLIC SEWER @ $7.00 " 7 SEPTIC"TANK,SEEPAGE PIT OR P.C.NO. PITS AND/OR DRAINFfELD CO. IMP.NO. JOB NO. $10.00 _ //^�� } HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. a PRIVATE DISPOSAL SYSTEM @ $3.00 O CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVEp EASEMENT RECORD. INSTR.NO. DATE u WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT.DRAINFIELD EXTN..CESSPOOL.DRYWELL. @ $5.00 O ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING �- SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT W MANHOLE 0 $7.00 PERMIT NO. d INDUSTRIAL to WASTE APPROVAL z OWNERS PERMIT $ s 00 CHARGES AUTHORIZATION TOTAL FEE //// CONNECTION CHARGE FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING N TO THE PUBLIC SEWER. APPROVALS DATE 1 ECTOR'S IGNATURE SIGNED THIS AAYI O 19_ . OWNEROR O //'�/- NEW HOUSE SEWER �C OWNERS AGENT LCCd'd� _/ CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK.SEEP.PIT(5) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑` IHEREBY CERTIFY THAT M PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR LICENSED AS REQUIRED O ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT M LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE A D RI ED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC KS ❑ OF pER MTTTEE SEEP.PIT( I)7 CEf ISPOOLS ❑ VALIDATION CK. M.D. `ASH 6 1 N SEP 8 1 0 D 1 0,0 0- 0 M ' A 1 76A 6420-CE808 -10-71 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISP SAL. IDEPARTMENT OF COUNTY ENGINEER _ BUILDING AND SAFETY DIVISION BUILDING ADDRESS LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST. j LEGAL L DESCRIPTION LOT NO. V OWNER MAIL / BLOCK TRACT ��(�/� ADDRESS NO. OF BLDGS. l- SIZE OF LOT ✓ NOW ON LOT I CITY USE OF BUILDINGS DISTRICTNO. GROUP MAP PG PROCESSED BY CONTRACTO ,/V{i•(•�LI,'. dip'4..' i+ �/ XY L.J ADDRESS Lr CONNECTION DATA CITY �� TEL. NO. ' TION DEPTH STATE / LICMANHOLE REFERENCE.//q LICENSE NO, �/ ✓ GLASS +� C LOWER NO. I DESCRIPTION OF WORK FEE T E OF C NE 10 LENGTH FlIiOM / HOUSE SEWER CONNECTING TO Yv M.L.TO P.L. / PUBLIC SEWER @ $7.00 iy P.C.NO. SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. �( C- PRIVATE DISPOSAL SYSTEM @ $3.00 `� O CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER -EAIEmE RECORD. INSTR.NO. DATE u WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT.DRAINFIELD EXTN..CESSPOOL.DRYWELL. @ $5.00 O ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING I--. SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT I,i! MANHOLE@ $7 00 PERMIT NO. a N ^ H INDUSTRIAL y WASTE APPROVAL b CHARGES OWNERS PERMIT $ AUTHORIZATIONJ TOTAL FEE © CONNECTION CHARGE FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK.SEEP,PIT(S) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSED AS REQUIRED OS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I E EGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE A O E BED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER SIGNATURE �j �, ❑ OF PER MTTTE L/- \ BACKFILL SEPTIC TANKS - SEEP P)IT(S) P+--CESSPOOLS Fl VALIDATI / CK. M.O. CASH