HomeMy Public PortalAbout9538 BLACKLEY ST_Sewer__ DEPARTMENT OF COUNTY ENGINEERa-
SEWER—SEdVAGE DISPOSAL '
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
t WILLIAM J. FOX, COUNTY ENGINEER BUILDING tet+
i ADDRESS
FOR APPLI NT TO FU IN LOCALITY
AD BUILDRESS /� �� CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
/1���1 �/ rl �^ J c
NEAREST �j� G "� A J
/���/
CROSS ST. RECEIVED BY Ready for Inspection DATE ISSUED
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OWNER ��I/�_�JC� /d� G=4
MAIL USE ZO OCCUPAN Y MAP
ADDRESS I I BK PG
CITYaj /� TEL.NO�j3 JP I
CONTRACTOR l�Q. CO.IMP:.NO.
ADDRESS �. JOB.NO.
CITY � ' i104�eo 9(TEL.NO. z2vilfl TRUNK PERMIT NO.
/ D D� ❑ STATE
REGISTRATION NO. ,� e ❑ COUNTY ROAD PERMIT NO.
LEGAL 'O ( STATE ENCROACHMENT
DESCRIPTION LOT NO. / PERMIT NO.
BLOCK TRACT 1 INDUSTRIAL
WASTE APPROVAL-
SIZE OF LOT �� NOW ON LOTS I
CHARGES
USE OF
BUILDINGS //��/JC�' /,}/�/��� CONNECTION CHARGE F E\
NO. DESCRIPTION OF WORK FEE
� REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER $ 3.50 I RECEIPT NO. I DATE I BY
HOUSE WE CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 NO.
ALTER OR REPAIR EXISTING DATE BY
SEWER OR DISPOSAL SYSTEM 1.00 I I c
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 ; ONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION / DEPTH
CESSPOOL—DRYWELL In
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFE LOWER
TYPE OF bbNNECTION LENGTH MOM
OWNERS PERMIT $ I 1 00 P L. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING C APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER -
SIGNED THIS.___�_e_; --.DAY OF..__. .. _____. /......._.._._19v NEW HOUSE SEWER j�
OWNER OR CONNECT ADDITIONAL
BUILDING OR WORK
OWNERS AGENT--- -- - .. .. -- _..._ - a --•-�/"�--�-'
SEPTIC TANK,SEEP.PIT(S)
ADDRESS... ... _.G�-__--.-_.. --•-` ---�'f'�'� � �' AND/OR DRAINFIELD
I HEREBY CKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL DRYWELL(]
CAT
IONAND 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 I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR T I AM THE LEGAL OWN
ER OF THE ABOVE CRIB R ID NTIAL*PEA# BACKFILL SEPTIC TANKS 0
SIGNATURE SEEP.PIT(S)0 CESSPOOLS
OF PERMITTEE _____ r _..... _ _.!y!! ._._... ___ ....
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