HomeMy Public PortalAbout9554 BLACKLEY ST_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS
FOR APPLICAN O FILL IN - LOCALITY
�li �.
BUILDING NEAREST
ADDRESS CROSS ST.
LOCALITY DISTRICT NO.• SERIAL N0. PERMIT N0.
NEAREST /D �,/ / C� A , S
CROSS ST / f.�
�// RECEIVED BY Ready for Inspection DATE ISS
P /� D
OWNER e// ���q ! ��
ADDRESS IVJ /, 'j�Q�f� /�a� USE ZO E OCCUPA Y I• MAP BK. PG
MAIL
CITY�� TEL.NO. / -•z
CONTRACTOR CO.IMP.NO.
ADDRESS �� pG df JOB NO.
CITY. �Gj !/TEL.NO. �� / TRUNK PERMIT NO.
I
STATE
REGISTRATION NO. /J COUNTY ROAD PERMIT N0.
i
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT � WASTE APPROVAL
USTRIAL
SIZE OF LOT 4-6 x LD
NOW ON TS CHARGES
USE OF
BUILDINGS �,_ �iGCt'�_/ CONNECTION CHARGE FEE
NO. I DESCRIPTION OF WORK: FEE
+ HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
! 1 PUBLIC SEWER @ $ 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 I BY
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 STATION �✓ DEPTH
CESSPOOL DRYWELL
S62
PECIAL CONDITIONS ONLY 2.00 c0 QIANAOLE REFEREN E
UPPER J.BWER
TYPE OF CONNECTION LENGTH F M
OWNERS PERMIT $ 1 00, +R P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE GG .
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE, DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS__ DAY OF-...- _____-.-_ a_..__.....19✓ NEW HOUSE SEWER r,�s Ow-:
- CONNECT ADDITIONAL
OWNER onOWNERS AGENT_. ---- � .� BUILDING OR WORK
' f2lrFsL _ SEPTIC TANK,SEEP.PIT(S)
ADDRESS--.--__- �CI�-.--___----_________- ---•- AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- •CESSPOOL❑ DRYWELL�-
CA NON 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 TH&;G•l AM THE LEGAL OWN-
ER OF THE ABOVE D SCRIBED SID�L7PROPERTY. BACKFILL SEPTIC TANKS
SEEP.PIT(S)� CESSPOOLS E
SIGNATURE '
OF PERMITTEE. _... vt
76A642D 663 1/53