HomeMy Public PortalAbout9542 BLACKLEY ST_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWED—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
. ADDRESS
FOR APPLIyCA TILL IN LOCALITY
ADDRENEAREST
SS ��!p�rj � ��� CROSS ST.
BUILDING
LOCALITY ,o Lp� f DISTAUCT NO. SERIAL No PERMIT NO.
CNEARESTROSS ST. ✓ /'/ GS r`� - A fo� T J3/0
RECEIVED BY Ready for Inspeotion DATE ISSUED
OWNERMAIL
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ADDRESS ;�rV7 USE Z E OCCUPA I
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CITY � ��'�TEL.NO 3�Z,3 1 �)/n
CONTRACTOR `f CO.IMP.N0.
ADDRESSD i� '� JOB.NO. \ �I
CITYe4TEL.N0
�i. / / TRUNK PERMIT NO.
REGISTRATION NO. (J ✓O OUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. PERMIT NO.
BLOCK TRACT INDUSTRIAL
Y WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS. CHARGES
NOW ON LOT
USE OF
BUILDINGS ��� $ ����CTi CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ; 3.50 V RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SNO-
1.00
ALTER OR REPAIR EXISTING I DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 I CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 I STATION Q DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 l` NHS EFERENCE LOWER
TYPE OF CO ECTION LENGTH FRdim Al —7
OWNERS PERMIT = I 1 00 Y - ---GU418 P.L. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE I Ec3cv -
CO THAVE THIS DATE CONTRACED WITH THERACTOR TO CONNECT THE ABOVE D SCRIBEDIEXISTING' APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO TH kDAY
SEWER
SIGNED THIS--- OF__._. ... NEW HOUSE SEWER
OWNER OR / - ,�I - CONNECT ADDITIONAL -�
OWNERS AGENT _-_ BUILDING OR WORK
SEPTIC
ADDRESS_-_--_--__-�-_ ih _ ��. AND/OR DRAINF ELD PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL E] DRYWELL D
CATION AND 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 LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABO SCRIBED SIDE IAL PROPERTY. BACKFILL SEPTIC TANKS
���/// SEEP.PIT(S)[] CESSPOOLS
SIGNATURE •
OF PERMITTEE--- .- ..—- ! -
76A642D 663 1/53