HomeMy Public PortalAbout5084 SULTANA AVE_Sewer__ APPLIC TION FOR ISERMIT
COUN" OF LOS ANGELES SEWER-SEWAGE DISPOSAL
MARTDUNT OF CODNTY ENGINEEE
SUMI)ING AND SAFETY DriMON BUILDING
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NEAREST
FOR APPLICANT TO FILL IN CROW 9T
UESCERIGPTIOR LOT No 200E OWNER L
BLOCK TRACT _ MAIL
ADDRESS
NO OF SLOG
SIZE OF LOT NOW ON LOT 1
USE OF
BUILDING . DISTRICT NO GROUP BE RAP M PROCESSED BY
CORTRACTOR
ADDRESS CONNECIION DATA
CTR TEL NO p STATION Q DEPTH
qq STATE MANHOLE REFERENCE / PPER
REGISTRATION 110F COUNR J
NO 11 DESCRI T R FEE
VUUfE SSEWERR EWER CONNECTING TO SS 00
SEPTIC T RK SEEPAGE PIT OR TYPE OF CONNECTIO LENGTH FROM
PITS AND,
DRAINFIELO 0 Y CURB M L TOP L O
OVERFLDW SEEPAGE PIT DRAINFIELD
CESSPOOL DRTW EL Z 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE 1 EY 1 00 CO IMP NO D JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
7: SWORK TO HOUSE SEMER
A T SIR EPAIROR ABA NDON HOUSE STATE ENCROACHMENT
XL Sy1 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMT 2 DD CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTS DATE A CONTRACT WITH THE IING NAMED
DW E ON
LUNG OVALS DATE INSPECTOR 9 SIGNATURE
TO THE PUBLIC SEWER (
SIGNED THI OF 9— NEW HOUSE SEWER J� r
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRE SEPTIC TANK SEIELDPIT(S)
I
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE I! CORRECT AND AGREE TO COMPLY CESSPOOL DRTWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS ALTER REPAIR SEWER OR
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AN THE LEGAL OWNER OF THE ABO ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPER BACKFILL SE C TANKS
SIGNATURE SEEP PITS CESSP00 w
OF PERYITTE
®P
VALIDATION'— ROBERT A WOOD
CL ■ G SUPERVISING MECHANICAL ENGINEER
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