HomeMy Public PortalAbout5022 SULTANA AVE_Sewer__ SOS3
SA542 -"
7APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DNffilON BUILDING
OFRI A, LAB B ADDRESS
V A. sup i d B. d.G_ LOCALITY 1
NEAREST
�g CANT O CROSS et
LEGAL _
DESCRIPTION LOi NO O OWNER
BLOCK TRACT �= -� MAIL�
110 OP BLDGB
81ZH 0!LOT MOW ON LOT 1
UBE OF
BUILDING DISTRICT NO ROUP YAPgDATA
ID BY
CONTRACTOR
ADDRESS / CONNECIIONCITY N STATIONSTADIREGISTRATIOR HO COUP MANHOLE REFERENCE O / UPPER
No {1DaESCRI FQ O�
OBLICSt CONNECTING TO ,j
SEPTIC TAN[ SEEPAGE PIT OR T TYPE OR Cu:Nt[RIO P L NIL TONGTH KOM OC'
PITS AM OR DRAT NFIELD3,00
OVERFLOW SEEPAGE PIT DRAIMPIELD
OUSE ERCONNE IMG TO tloo P C O O
Cr �� CO INP RO JOB NO
ORE TOT AO DITIONAL SLDG UR TRUNK PERMIT No ROAD PERMIT NO O[
A TQ N AIR O SAM N HOUSE STATE ENCROACXYlNT
IgM1T NO ILLJ
INDUSTRIAL OL
WASTE APPROVALy
CHAROMZ
Off'$ I PEBW s Y 00 CONNECTION CHARGE FE[
AUTHORIZATION TOTAL FEB REIMBURSEMENT FEE
I
HAVE AT TH18 DATE A CONTRACT WITH THE XOI[IN HAYED COR- n
TRACTOR 70 CONNECT THE ABOVE DESCRIBED QISTINO DW[WRO APPSO n/ INtKROR itIOM4TUR6
TO THE PUBLIC DE•
SIGNED TH AY OP _ 1 NEW HOUSE SEWER I -
OWNEROR CONNECT ADDITIONAL
OWNERS A6®ff BUILDING OR WORK I
ADDP AND/OR DRAINFIELDIC TANK SEEP PIT(t)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COMPLY CESSPOOL DRTW[LL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMS 11 AND SEWERS SEWAGE DISPOSAL SYSTE /
I HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND ATE OF ABANDON HOUSE SEWER /
CALIFORNIA OR THAT 1 THE LK Q OJ ABOY[
DESCRIBED RESIDE MTIA 'BACKFILL SE C TANKS ., / /
SEEP PIT t CISSPOOLt / G J/i A
SIGNATURE
OF PERYI
VAIMATIODY� ROBERT A WOOD
CL M 0 OAtS SUPZRVISING MECHANICAL.ENOIPIRM
-20_ X 29 i o A 7.00- 8
i