HomeMy Public PortalAbout9575 BLACKLEY ST_Sewer__ 76A642 0-63
0-63
7APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING r-
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER 1'
BLOCK TRACT MAIL / ./�/
v ADORE X!/� r�� (
Nb OF B GS.
SIZE OF LOT NOW ON LOT CITY TEL -NO.
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDING BK PG
CO i �OVj Q
ADORES CONNECTION AT
• STATION `� DEPTH
CITY L N �J
❑ 651
5 ATE MANHOLE REFERENCE /1/ �O v `3 UP
REGISTRATION NO �� ❑ COUNTY ( v
N DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FR6M r
POBLIC SEWER CONNECTING TO @ $5.00 - Y CURB P.L. M L.TO P.L. }
SEPTIC TANK,SEEPAGE PIT OR P.C.NO '' O
PITS AND/OR DRAINFIELD @ S1000 CO.IMP. NO JOB NO. /"`CCC^ `
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ S3.00 I=
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO. DATE O
WORK TO HOUSE SEWER @ $300 V
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN,CESSPOOL,DRYWELL,MANHOLE @ $5 00
ALTER.REPAIR OR ABANDON HOUSE HWY OR ST WIDENING y
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
I PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER$ PERMIT S z 00
AUTHORIZATION TOTAL FEE D CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWERA /e✓f tE�"J7 +:' `,�
OWNERS AGENT CONNECTADDITIONAL 4 ✓
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 15 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 REQUIRED BY LOS ANGLES COUNTY ANDATE OF S EW AGE DISPOSAL SYSTEM
CALIFORNIA OR I M THE LEGAL O OF NO I END TO DISCONNECT PLUG AND
RESIDE IN, T ABOV DESCRIBED RE DENT L OPE N HOUSE SEWER
SIGNATURE l BACKFILL SEPTIC TANKS 1:3OF PERMI SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK M.O CASH
L;ilr0 6 4 8 7:a DEC 4 1 G D 7.C1 QH