HomeMy Public PortalAbout9549 BLACKLEY ST_Sewer__ )QEPAI TENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM?J. FOX. COUNTY ENGINEER ; BUILDENGps—��
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY ?'cam
,BUILDING �•-' NEAREST .�
ADDRESS t7 CROSS ST.
LOCALITY 1 DISTRICT N0. SERIAL N0. PERMIT N0.
NEAREST A `--��-
CROSS ST. y�®�0 �o �}� /, /+ RE EVE :BY Ready for Inspection DAT ISSUED
OWNER
MAIL � 9 yM�G � U ONE OCCUPANCY MAP
ADDRESS / OCC BK PG
CITY �TEL.NO.- �� �/�1 -�• �` Q�
CONTRACTOR
ADDRESS f
JOB N0.
CITY TE NO f
TRUNK PERMIT NO.
STATE
REGISTRATION N ZZLI, COUNTY ROAD PERMIT NO. Z Q
LEGAL
DESCRIPTION LOT NO. 6OE� / STATE ENCROACHMENT.
y PERMIT NO.
BLOCK TRACT � �` A/ INDUSTRIAL
a x'56:1 WASTE APPROVAL
SIZE OF LOT / N0.OF BLDGS.
NOW ON LOT CHARGES
USOF r
BUE DINGS r CONNECTION CHARGE FEE�Q �7,5— =?r G
NO. •DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FE
PUBLICSEWER @ $ 3.50 D *�RECEIPT rySAT�E { BY
HOUSE SEWER CONNECTING TO / 7 0.7�
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED -
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIREXISTING NO.
SEWER OR DISPOSAL SYSTEM 1.00
.DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATIONt�D�Q DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 plyQ�/� MA UPPE EFERENCE
TYPE OF CONNECTION LENGTH FFROM'5
OWNERS PERMIT $ 1 00 Y �ctJ� " [s? M.L.TO P.L.
AUTHORIZATION TOTAL FEE I !!L,152'
I HAVE THIS DATE CONTRACTED WITH THE HER IN NAMED
CONTRCTRDWELLAINGOTOTTHEOPUBL CTSHE EWER VE DESCRIBED EXISTING APPROVALS INSPECTOR'S
0SIGNAfURE DATE
SIGNED THIS-2n�- AY OF.-_..........._--_-. ............191s_-% NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT,.,,.-...- ._----- ------ . . BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
_. .-
ADDRESS._ �F .-.... _ - _.-.:. .�_. AND/ORDRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL Ej DRYWELL
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
AND STATE OF CALIFORNIA OR THAT I THE LEGAL WN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED
DESCRIBED gE�A�CL PRqpERT BACKFILL SEPTIC TANKS
SIGNATURE //j(� %- SEEP.PIT(S)[] CESSPOOLS
OF PERMITTEE-(L-�--=._...-........ --- ------ - -- --- -- --
76 642D 603 1/53