HomeMy Public PortalAbout9683 BLACKLEY ST_Sewer__ CE808 10-63
76A642D APPLICATION R PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO L IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. •I OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. N
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
�\
CONTRACTOR
ADDRES ` n CONNECTIO DATA
CITY TEL. NO. / > STATION .'�j.LD DEPTH
_ TATE MANHOLEOREEFEERENCE _ UPPER
REGISTRATION NO. COUNTY;" tz L
NO. DESCRIPTIO OF WORK FEE TYPE O CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. ,
PUBLIC SEWER @ S5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO.
NO
PITS AND�OR DRAINFIELD @ SIO.00 CO.IMP. NO. (� JOB NO. V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO
A
PRIVATE DISPOSAL SYSTEM @ S3.00 !lG V 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD. INSTR.NO, DATE
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD 6!J
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ S5.00 d
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING h
Z y
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT S
PERMIT NO.
)' INDUSTRIAL
f. WASTE APPROVAL
CHARGES
OVMER'S PERMIT S 2 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN 14AMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING •.
' TO THE PUBLIC SEWER. APPROVALS DATE INSPECT R'SSIG NATURE
SIGNED THIS DAY OF 19_ _
OWNER OR NEW HOUSE SEWER
OWNERS AGENT i
CONNECT ADDITIONAL
L ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
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 PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A VE DES RIBED R ENTI PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITT BACKFILL SEPTIC TANKS ❑ ��S / _.
SEEP,PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.0. CASH
Lko 8 4 8 4 MAY 10 1 0 D 7.0 0