HomeMy Public PortalAbout9548 BLACKLEY ST_Sewer__ DEPARTMENT OF COUNTY ENGINEEIb
SEWER-SEWAGE DISPOSAL
DIVISYON OF BUILDING AND SAFETY
PERMIT APPLICATION OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANTTQ APPLICANT
ZIZILL I LOCALITY
BUILDING ADDRESS � NEAREST
� ���0 G�'e CROSS ST.
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'y.,T'�iICT NO. SERIAL NO. PERMIT
/jPPERMIIT NO. C
LOCALITY �,O T/�JJ�I ` ,5 r'a\ A [ < /I ty� J
NEAREST �.-�G/
CROSS S '
RECEIVV/E}�_D B�Y Ready for Inspection `fDATE ISSUED
OWNER �/ �� ��J L'�r�~Y / 1 -3ii
MAIL
ADDRESS � �a USE ZONE OCCUPA MAP
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CITY �l-a %���� �� (/,{/�',
TEL.NO.
CONTRACTOR �j , c' �-� t`" �
� CO.IMP.N0.
ADDRESS r6f � �
17 JOB N0 �
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CITY 1__I;�? ellV�ITEL,NO.�' �
TRUNK PERMlT N0.
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REGISTRATION N0. COUNTY ROAD PERMIT N0.
LEGAL A _
DESCRIPTION LOT N0. l0 STATE ENCROACHMENT
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PERMIT NO.
BLOCK TRACT ���`''• ,J11J7� INDUSTRIAL
SIZE OF LOT • N0.OF BLDGS. WA8TE APPROVAL
NOW ON LOT, CHARGES
USE OF
BUILDINGSCONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE '
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLICSEWER (ap $ 3.50 RECEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- I DATE BY
SEWER OR DISPOSAL SYSTEM 1.00.
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR / 'in
PITS AND/OR DRAINFIELD 2.00 STATION �k� ''"'— DEPTH ��
CESSPOOL—D RYW ELL
SPECIAL CONDITIONS ONLY 2.00 �ANHOLE REFERENCE/ I
& UPPER LAS L'OwER
T�ONNECTION LENGTH FROPI
OWNERS PERMIT $ 1 00 P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE /
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOV DESCRIBED EXISTING APPROVALS INSPECTOR'SSIGNATURE DATE
DWELLING TO THE PUBLIC .SEWER F i
SIGNED THIS_____ .DAY OF----- _ _ � 19 ��` NEW HOUSE SEWER ( 1� -
_.._ �' C�
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT..!- r__ ��� p " �; BUILDING OR WORK '
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ADDRESS...
_: G, t_ G.l� .. SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL[] DRYWELL F-]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
1 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 THA7T,; AM THE LEGAL OWN-
ER OF THE ABOVE D SCRIBED R IDENTIAL�PROPERTY. BACKFILL SEPTIC TANKS
SEEP.PIT(S)E) CESSPOOLS❑
SIGNATURE /� � _
OF PERMITTEE - ='='L==-�.�::.....-----•--
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