HomeMy Public PortalAbout9564 BLACKLEY ST_Sewer__ 2
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76A642D 0-63 APPLICATION OR PERMIT
A64JU
COUNTY OF LOS ANGELES SEWE�,7DIS-SE O AL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING®r^
JOHN A. LAMBIE, County Engineer ADDRESS %07
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST
LEGAL
DESCRIPTION LOT NO OWN
MAIL
BLOCK TRACT AD S J\
O OF BLDGS N
SIZE OF LOT NOW ON LOT CITY c- tTEL NO.
USE OF i DISTRICT NO GROUP BK PG
Jr, MAP PROCESSE Y
BUILDIN
S�
a
1ADDRE CONNECTION DIATX
S ON 91 DEPTH
CIT TE
❑ TA MANHOLE REFERENCE /
GISTRATION NO Q ❑ COUNTY
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH F M
HOUSE SEWER CONNECTING TO T Y CURB P.L M.L TOP
PUBLIC SEWER @ $5.00 0-D O-
P.C.NO. O
SEPTIC TANK,SEEPAGE PIT OR CO IMP NO, A08"�D4.
PITS AND/OR DRAINFIELD @ $10 00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO. 9x
PRIVATE DISPOSAL SYSTEM @ 33 00 ^
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT w�lY[R E�SEMEHT RECORD, INSTR NO. DATE
WORK TO HOUSE SEWER @ S3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN,CESSPOOL,DRYWELL.MANHOLE @ $5 00 d
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ S3 00 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE a�z? CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN MED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRI D EXISTING DWELLING
TO THE PUBLI WER APPROVALS DATE INSPECTOR'S SIGNATURE
.cam:r�
SIGNED THIS��AY OF 19_
OWNER OR NEW HOUSE SEWER �p� � �
t
OWNERS AGENT CONNECT ADDITIONAL '
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP.PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND OR ALTER, REPAIR,SEWER OR
LICENSED AS REOUIR Y LOS ANGLES COUNTY AND S E OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T I THE LEGAL OW OF, AND TEND TO DISCONNECT PLUG AND
RESIDE IN, THE OV THE
RESI NTAL PRO RTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTE BACKFILL SEPTIC TANKS El ❑
EP.PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
L,�i�c 6 4 8 5%-01 DEC 4 1 0 0 7.0 0 N "