HomeMy Public PortalAbout5033 SULTANA AVE_Sewer__ CBACee eO APPLICATION FOR PERMIT
TeAe�:o COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGuMM
BUILDING AND SAFETY DIVISION ADILDINO
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HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N ED CON-
OR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS ATE INSPECTOR 5SIQNATURE
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OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _ BUILDIi1G OR WORK
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AND/OR DRAINFIELD
1 XEREBT THAT
THE AB THAT 1 CHAVEORRECT
READ THIS APPLICATION - - -WANDITH
STATE THAT THE ABOVE IS CORRECT STATE
AGREE TO COYPU CESSPOOL DRTWELL 13
PITH ALL COUNTY ORDINANCES AND STATE LAdB REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWERS S SEWAGE DISPOSAL SYSTEM -
I XEREBT CERTIFY THAT I AM PROPERLY REGISTERED AMD/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES NTY AND STATE OF ABANDON ROUSE SEWER
CALIFORNIA OR THAT AM THE OWNER OF T E ABOVE
DESCRIBED RESIDEN RO TY ` BACKFILL SE IC TANKS ❑
SIGNATURE
SEEP PIT 9 CESSPOOLS
-
OF PERYITTEgal
VALMATION-'I ROBERT A WOOD
CL M 0. CAstl SUPERVISING MYCHANIC••• RNOINEER
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C6APPLICATION FOR PERMIT
TBA6420 eAaD COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
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ADDRESS 0 • CONNECTION DATA
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ATE MANHOLE REFERENCE UPPER
REGISTRATION NO Q COUNTY LOWER
NO DESCRI ION OF WORK FEC TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TO P L
PUBLIC SEWER Y ssoo
SEPTIC TANK . [PAGE PIT OR P C NO
PITS AND/OR DRA INFIELD C sloop CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM O ES m
CONHCCT ADDITIONwL BLDG OR co AFFIDAVIT [• [At[S[LIT RECORD INBTR NO DATE
WORK TO HOUSE SEWER O 53M
OVERFLOW SEEPAGE PIT GRAINFIELD
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ALTER REPAIR OR ABANDON HOUSE Y E ID Niry
SEWER OR DISPOSAL SYSTEM 0 SS GO STAT[ENCROACHMENT
PERMIT NO
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WwST[APPROVAL
CHARGES
OWNERLS PERMIT t i 00
AUTHOBUATION TOTAL FEE a CONNECTION tOE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN HAMRO CON REIMBU MEHT FCE
TRACTOR TO CONNECT THE ABOVE DESCRIBED BRI.TING DWELLING *n�BO�
TO THE PUBLIC SEWER AP DATE INSPECTORSSIONATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOU.[SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS WILDING OR WORK
1 HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTICANK p![P PITIS)
AND STATE THAT THE ABOVE IB CORRECT AND AOR[[ TO COMPLY pRAINFI[LO
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS OL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND�ORREPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF DISPOSAL SYSTEM
CALIPORN4 OR THAT I AM TNB l[OAL WN[ AND INTIND TORC61D[ IN THE ASOVE\GESCRIS[D ES CNT PROP YNECT SESLUG AND
L�/`F1N HOUSE S[W'[R
SIGNATUREOF PERMTTTE L BE, TANKS ❑
TIS) ❑ CESSPOOLS
/1V ATION ROBERT A WOOD
(/CVK /�� M O DASH SUPERVISING MECHANICAL ENGINEER
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