HomeMy Public PortalAbout9574 BLACKLEY ST_Sewer__ 0-63
76A642D APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER-SE EDI P SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building
FOR APPLICANT TO FILL IN
LEGAL '
DESCRIPTION LOT NO Y OW
BLOCK TRACT / ADDRES
N6..OF BLDGS
SIZE OF LOT NOW ON LOT CITY - C_ 'TEL. NO.
USE OF —)T— DISTRICT NO. GROUP MAP PROCESS BY
BUILDING
BK PG
/yam
CONTRACT J
CONN
ADDREss IO
STATION DEPT
CIT TEL.
STATE
MANHOLE REFERENCE
REGISTRATION NO ❑ COUNTY OWER
NO. DESCRIPTION OF WORK FEE TYi5E OF CONNECTION LENGTFROM -
HOUSE SEWER CONNECTING TO Y CURB P L_ H M.L TO P L }
PUBLIC SEWER @ $5 00 P C NO. d
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP NO O
N
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ S300
OVERFLOW SEEPAGE PIT,DRAINFIELD V
W
ALTER.
ESSPOOOR ABANDONMANHOLE @ $5.00 HWY OR ST.WIDENING a
ALTER,REPAIR OR ABANDON HOUSE En
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT _z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 Oo
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREI AMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E ING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THISDAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT 'LgAz
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERE AND/OR ALTER, REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGL UNTY AND TATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T I AM THE LEGA N R O AND TEND TO DISCONNECT PLUG AND
RESIDE IN, T AB DESCRIBED SIDE IA PROP TY. ABANDON HOUSE SEWER
SIGNATURE f ILL SEPTIC TANKS ❑
OF PERMIT. EE SEEP,P •}-❑ CESSPOOLS ❑
ALIDATIOROBERT A. WOOD
CK M O CASH
SUPERVISING MECHANICAL ENGINEER
L,:wo
6 4 & 6 DEC 4 1 0 D 7.00-