HomeMy Public PortalAbout9611 BLACKLEY ST_Sewer__ I)F.PARTMENT OF COUNTY E��TGINF.ER L' !
- DIVISION OF BUILDING AND SAFETY SEl�EIi-SEiNAGE DISPOSAL
' ,PEkMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDINO (�/ / �1/
AND Y
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FOR APPLICA Y-TO FILL LOCALITYBUILD
—ADORNG 0�-e NEAREST
E 6 • CROSS ST.
LOCALITY DISTRICT NO. SE�RRIALLfNOf PERMIT NO. C
NEAREST /(/ / -7�'
CROSS sr.
REC LVED BYO/ Ready for Inspection D E ISSUED'
OWNER . Zo
MAIL F "USE ZON,E� OCCUPANCY �'14Y/tP�
ADDRESS S� 'L / C v
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CITY r—�_ TEL.NO. �/ I �S I 4
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CONTRACTOR I
ADDRESS --�
JOB.NO.
CITY TELAO. TRUNK PERMIT N0.
STATE
REGISTRATION NO. , B COUNTY
ROAD PERMIT N0. �
LEGAL E 214 d C5
DESCRIPTION LOT NO. ,�. ,r STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT���s 0� ��LI� �' t INDUSTRIAL
1 WASTE APPROVAL
SIZE OF LOTNO.OF BLDGS.
NOW ON LOT CHARGES
USE OF =
BUILDINGS CONNECTION CHARGE E
NO. ' DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 3.50 RECEIPTN0. X DATE IBY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR / ®O EXCEPTION RE ROED
1.00'
WORK TO HOUSE SEWER
ALTER OR REPAIR EXISTING / NO- I DATE + BY
_SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYW ELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
PPE-R--- LOAER.,
TYPE_OF_CONNECT.ION_ LENGTH_FROM
OWNERS PERMIT I 1 00 Y CURB P:
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'SSIGNI?xURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS---�_._-....DAY OF...i� __.... NEW HOUSE SEWER
OWNER 0R CONNECT ADDITIONAL /
BUILDING OR WORK
OWIi.Ef3S—Afli,rr--...T....._......_.._......_.._........-�...».........,.......: ,
y .SEPTIC TANK,SEEP.PIT(S)
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ADDRESS........�..� �._� t= AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[:] DRYWELL E]
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATINGPLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN. ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS E]
SIGNATURE SEEP.PIT(S)[D CESSPOOLS❑
OF PERMITTEE------ ''� ..................................
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