HomeMy Public PortalAbout9588 BLACKLEY ST_Sewer__ 0-63
76A6426A6420 APPLICATION FOR PERMIT y
COUNTY OF LOS ANGELES SEWER—S E G E DSP SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDIN
JOHN A. LAMBIE, County Engineer ADDRESS J
WILLIAM A. JENSEN, Supt of Building
LOCALITY r
NEAREST
FOR APPLICANT TO FILL IN CRDSS S
LEGAL
DESCRIPTION LOT NO OWNER R
^/' MAIL
BLOCK TRACT /o ADDRESS
OF BLDGS
SIZE OF LOT NOW ON LOT CITY JEL NO.
USE OF DISTRICT NO. GROUP MAP P OCESS BY
BUILDIN S I �� � BK _ PG 2 3 f
CON TAR / If 1/./
AD RESSCONNECTION T
CIT TEL . TION DEPTH
STATE MANHOLE REFERENCE UPPER
RE 1STRATION NO ❑ COUNTY ` LOWER
N DESCRIP ON OF?-WORK FEE TYPE OF CONNECTION LENGT FROM
HOUSE SEWER CONNECTING TO Y. CURB P.-. M L Te...L. r
PUBLIC SEWER @ $5 00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO 6
N 0
PITS AND�OR DRAINFIELD @ $1000 CO IMP. NO. 1O�"
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 lJJ
EXTN,CESSPOOL,DRYWELL.MANHOLE @ $S 00 a,
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT z
PERMIT NO
INDUSTRIAL
OWNERS PERMIT
WASTE APPROVAL
CHARGES
S z o0
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL C l!
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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROP RLY REGISTER D AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS AN S COUNTY A STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORN OR THAT I AM THE L NER OF, A D INTEND TO DISCONNECT PLUG AND
RESIDE ABOVE DESCRIB RES EN I L P PERTY ABANDON HOUSE SEWER
SIGNAT E BACKFILL SEPTIC TANKS ❑
OF P SEEP,PIT(S) El CESSPOOLS ❑
VALIDAT ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
Lnl,o 6 4 9 0 Dc 4 1 0 D 7.00,