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Home My Public Portal About9591 BLACKLEY ST_Sewer__ -p- -k -7 M CE80810-63 -APPLICATION FOR PERMI 76A642D COUNTY OF LOS ANGELES SEWER-SEW E DI P SAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDIN 1j JOHN A. LAMBIE, County Engineer ADDRESS WILLIAM A. JENSEN. Sup't of Building LOCA LiTV NEAREST FOR APPLICANT T FILL IN CROSS 5T. LEGAL 2 DESCRIPTION LOT NO. OWN MAIL BLOCK TRACT ADDRESS NO. OF BLDGS. -•rEL. NO. SIZE OF LOT NOW ON LOT CITY USE OF DISTRICT NO. GROUP MAP PROCESSED BY BUILDINGS BK _ PG CONTRAG O ©� ADDRESS !�+ CONNECTION DATA CITY 5tT�L -C'. ' STATION -�¢- DEPTH ❑ STATE //////��1��1 // UPPE _- MANHOLEFERENCE D REGISTRATION NO. ❑ COUNTY OWER NO. GESCRIPTI N OF WORK FEE TYPE OF CONNECTIO LENGTH FRdM ) HOUSE SEWER CONNECTING TO Y. CURB C P.L. M.L.TO P.L. PUBLIC SEWER 65.00 SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O PITS AND/OR DRAINFIELD @ 510.00 CO.IMP.NO. JOB NO. V HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. I=PRIVATE DISPOSAL SYSTEM 63.00 0 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER I EASEMENT RECORD.INSTR.NO. DATE V WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELD - W EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING H SEWER OR DISPOSAL SYSTEM_ @ 83.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL OWNERS PERMIT $ 2 y0�0 CHARGES AUTHORIZATION rTOTAL FEE 7/� CONNECTION CHARGE FEE '1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE TRACTOR T0C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS TO THE PUBLISEWER. DATE INSPECTOR'S SIGNATURE SIGNED THIS D OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK 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 ❑ IHEREBY CERTIFY THAT I AM PROPERLY R GISTERED AN /OR ALTER,REPAIR,SEWER OR LICENSED AS REQUIRED BY LOS ANGLES C TY ANDSTA OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR TH T THE LEGAL O OF, A INT D TO DISCONNECT PLUG AND RESIDE IN, THE VE ESCRIBED REST NTIA P PER ABANDON HOUSE SEWER SIGNATURE OF PERMITT ACKFILL SEPTIC TANKS El SE CESSPOOLS ❑ C ALJ ROBERT WOOD M.0. CK. M.O. / SUPERVISING MECHANICAL ENGINEER CASH J _ �+ 1 4 1 D '7.0 '� L rU LCC �