HomeMy Public PortalAbout5074 SULTANA AVE_Sewer__ // /-7 5 `
&caellaa APPLICATION FORPERMIT
DIVISION OF BUTLDING AND SAFETY SEWER-SEWAGE DISPOSAL
DopoartiLont of Comte Enpinwa
Count? of Lm Angalm BUILDING
JOHN A LAMBIE COUNTY ENGINEER AODpEBB '
m CASSATT O GRIFFIN SUP T OP BUILDING
LocALm
F LICANT TO FILL IN CROSSS ST
LEGAL OWRER
DESCRIPTION L NO
PAIL
BLOCK TRACT 14 ADDRESS
NO OF BLDGS CITYTEL NO
SIZE OF 1.1411
NOW ON LOT
USE OF / DISTRICT NO GROUP I MAP
BUILOIN69 1 BR PG R
CONTRACTOR CALIF.SEWER CONST CO
ADDRESS 1317 COLEOROVE AVE. CONNECTION DATA
CITY MONTEBELLP'EL NO PA 1-5048 STATION PA DEPTH
MANHOLE REFERENCE
REGISTRATION NO ?— ❑ STATE LONER
❑ COUNTY
NO DESCRIPTION OF WORK FEE
ROUSE SEWER CONNECTING TO TYPE OF CONNECTIOY ! LENGTH FROM
PUBLIC SEWER Q $3 S o D CURB Y L TOP;8L
OM
TANK,SEEPAGE PIT 08
PITS AND/OR DRAINFIELD ® ss 00
OVERFLOW SEEPAGE PIT DRAINFIELDP C NO
EKTM CESSPOOL DRYWELL MANHOLE ® S 2 00 CO IMF NO.D �� JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 0 $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT 60DiRONALMLD OR l STATE ENCROACHMENT
WORK TE-HOeSS4EWER ® S 100 U PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® 1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT s o0
AUTHORIZATION TOTAL FREIMBURSEMENT FEE
EF _
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR 991GNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING .,
TO THE PUBLIC 9EY((.ir /J NEW ROUSE SEWER
SIGNED THI L "QTY OF 19 CONNECT ADDITIONAL
OWNER OR 2vzql' aC1 BUILDING OR WORK -
OWNERS AGENT ��77.��.. yy//� SEPTIC TANK,SEEP PIT(S)
ADORES' �S �lzzi . ;4244 1 AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND,STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIRED BY AN LES COUNTY D STATE OF DISCABANDONNHO PLUGUSE AND
CALIFORNIA OR THAT 1 T E WN EN
THE ABOVE
ER
DESCRIBED RESIDENTIA OP BACKFILL
SIGNATURE CESSPOOLS
OF PERMITTEE
JOHN A LAMBIE COON ER ,r-�yALMATION ROBERT A WOOD CHIEF PLBG INSPECTOR
Al 0 cX N!ACR 5 9 0 191 APR 3 0 1 0 A
6.0 0 M