HomeMy Public PortalAbout9539 BLACKLEY ST_Sewer__ 7SSoo-e sB APPLICATION ,FOR FOR PE IT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSA
3t DEPARTMENT OF COUNTY ENGINEER
BUILDBUILDING AND SAFETY DIVISION ADDRESS
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ADDRESS .7 3•- fGt.. I �
10HN A. LAMBIE, County Engineer ��
CASSATf D:GRIFFIN, Sup't of Building LOCALITY
NEAREST -
FOR APPLICANT TO CROSS ST.-
DESCRIPTION LOT NO. �' OWNER / ljiZm ® a / ST
BLVC _ TRACT MAIL
G ADDRESS
N0.OF BLDGS.
SIZE OF LOT OW ON LOT CITY TEL.NO..
USE OF
DI 2 J ]PERMIT
ISTRICT 0. GROUP MAP PROCESS;"Y
BUILDINGS LJ BK r �
CONTRACTOR �+ eL✓�Cj�)
ADDRESS CO CTION DATA -
CITY O B TEL-,NO. —210STATION' DEPTH
}} MANHOLE REFERENCE UPPER
REGISTRATION NO. J LOWER
NO. DESCRIPTION OF WORK FEE /
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 0 $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y. C RB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD I
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00CO.IM .N JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00 SEWER OR DISPOSAL SYSTEM HOUSE $1 003TATE ENCROACHMENT
NO.'
�� INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS• PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE O REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. . • �� /
SIGNED THIS�DAY OF a-' I9NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL'
OWNERS AGENT ��e /� i �J¢� BUILDING OR WORK
` SEPTIC TANK,SEEP, PIT(S)
ADDRESS C- �� AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND 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 I 'AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
LDESCRIBED RESIDENT L P PERTY. BACKFILL SEPTIC TANKS❑ _
SIGNATURE SEEP.PIT(SCESSPOOLS❑
OF PERMITT
®r, - ROBERTA.WOOD
VALIDATION
pa, U.p. CASE( SUPfiRY1S1NG MECHANICAL ENGINEER
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