HomeMy Public PortalAbout5141 SULTANA AVE_Sewer__ DEPAHThDMW OF OOUNW ELNCUTC M SEWER-,SEWAGE DISPOSAL 1
DMSION OF BUILDING AND SAFETY ' PERMIT APPLICATION
OOUNW OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BOILDING
ADORES$ S� � T
FOR APP%CANT O F L IN LOCALITY ,
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CITY TEL NO
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CO IMP NO
ADDRESS
JOB MO
CITY TEL NO TRUNK PERMIT NO
STATE
REGISTRATION NO B COUNTY ROAD PERMIT NO
LEGALSTATE ENCROACHMEN
DESCRIPTION LOT MO PERMIT NO
BLOCK TRACT /Z INDUSTRIAL
WASTE APPROVA
812E OF LOT 10 OF BLDG8
HOW ON LOT ARLES
USE OF
BU ILDI NOR J CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ! i 850 RECEIPT NO I D TE BY
HOUSE SEWER CONNECTING GTO
PRIVATE DISPOSAL SYSTEM 100 Aga
CORRECT ADDITIONAL BLOB OR EX PTION R RDED
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EXISTINA NO DATE BY
SEWER OR DISPOSAL SYSTEM 100
DISCONNECT AND ABANDON SEWER
AND OR OISPORAL SYSTEM 100 C0144ECTIO& DATA
P TANK SEEPAGE PITON
PITS ANO/OR DRAINFIELD 200 00 STATION DEPTH
CESSPOOL--DRYWELL
SPECIAL CONDITIONS ONLY 200 MANHWE
ER REFERENCE LOWER
TYPE OF CONNECTIOLENGTH FROM
OWNERS PERMIT : 1 00 r CURB P L r L TO P L
AUTHORIZATIONTOTAL FEE O
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS ]"I ECTORiBIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS DAY OF_ __— 19_ xEw HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT__ _ _ _ _ __ BUILDINGORWORK
SEPTIC TANKK,,BEEP PIT(B)
ADDRESS _ _ _ _ _ _ _ _ _ _ __ __ _ _ ___ ",AMD/OR ORAI NFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORD]MANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AMD/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALWORNOR THAT I AN E LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESC BED REBADENTIAW PROPERTY BACKFILL SEPTIC TANKS n
SIOMATURE
e. 7 SEEP PIT(8)0 CE88PoOL$0
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OF PERMITTE
75Ai,2A 052 T/59
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SEWER— WAGE DISPOSAL
COUNTY OF LOS ANGELES 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN DIISSS TTRRICTaNO /ORRO•UP J/p MAPP PS SSED BY
LOCALITY TC • CONNECTIO DATA
NUREST STATION DEPTH
CRop[ tr
Q MANHOLE REFERENCE _ UPPER
OWNER ` TYPE OF [KION LENGTH PROM .�
MAIL ✓G Y CUR ML TOPL
CITY • C TEL NO (� j`7 CO IMP NO JOB NO
LZOAL TRUNK PERMIT NO ROAD PERMIT NO
O[SCRIPTION LCT NO
AFFIDAVIT [unS SA•n Sv RECORD INSTR NO DAT[
BLOCK TRACT
NO OF BLDG[
SIZE OF LOT NOW ON LOT NWY OR{T W10[MINO /. •T
o
m[ or V
BUILDING{ B {TATE ENCROACHMENT
PtRNIT NO
ONTRACTOR �A Z Ps.i•V/1[.0 WASTE A
IAL CPP
INDUS APPROVAL
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C `' Z REIMBURSEMENT FEE C
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HOUSE SEWER CONNECTING TO Np NRa
PUBLIC{EWER lipON[w Houpt B[w[R 0 /J Z
i PLIC ANK {ELPAO[PI OR
ITS AND/ON DNAINFI[LD • CONNECT ADDITIONAL
NOUS[S[W[R CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM • SEPTIC TANK SEEP PITIS)
CONNECT ADDITIONAL BLDG OR AND/OR GRAINFIELD
WORK TO HOUSE SEWER •
OVERFLOW SEEPAGE PIT DRAINFICLD CESSPOOL ❑ DRYW[LL ❑
[RTN CESSPOOL ORYW[LL MANHOLE•
ALTER REPAIR OR ABANDON HOUSE
ALTER REPAIR SEWER OR
SEWER OR DISPOSAL SYSTEM • SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOU{[B[WCR
BACKFILL SEPTIC TANKS -/
SEN PIT(S) ❑ CEBSP OLS 141A
OWNEE'S Issuance Fee s
I HAREAD THIS
ALrMOBMTION TOTAL FEE VP ANOHfTATE THAT THE ABOVEH15 AT CORRECT AND AGREEAPPLICATION To COMPLY
WITH ALL COUNTY ORDINANCES AND STAT[ LAWS R[OULATIMO
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON PLUMBING AND SEWERS
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AMD/OR
TO THE PU,LIC S[WCR LICENSED AS REQUIRED BY LOS ANGLES COUNT' AND STATE OF
SIGNED THIS DAY OF IY_ CALIFORNIA OR THAT I AM THE LK94L OW HER OF AND INTEND TO
OWNER OR RESIDE IN THE AMO [SCR B [SIO[ TI A PROPERTY
'CWNERBADENT SIGNATURE �(_Swr�I/Y/_�
OF PERMTTTE[
TIOX
A
WORKERS COMPENSATI6N M G EALN
3 9 7rOCT 12 1 0 0 15.00 A5d
POLICY HOLDER: -#
POLICY NUMBER: -f3z3 51 Q
APPLICATION FOR PERMIT./ �/ 7
eaew 1 u i
COUNTY OF LOS ANOMM SEWER-SEWAGE ISPOSAL
MMABTMM OF COUNTY ENGLNEM
BU DING TAynNDDD SSAGPET�Y EDeIvVMON ADDRESS Mg
i*�L•a.ri'-C
Tr D• • °I LOCALITY
NEAREST
H APP C TO IN CROSS ST
LEGAL
DESCRIPTION LOT XJ OVRER
BLOCK TRACT MAIL
80 OF BLOBS ADDRESS
SIZE OP LOT NOV OR LOT CITY TEL N V
USE OF
BUI IN DISTRICT NO G UP Bi YAP Po CESSED By
CONTRACTOR
ADDRESS 4� C CTIO ATA
CITY TEL NO STATION !-+�
STATE MANHOLE RIFERENCL A UPPER
REGISTRATION NO COUNTY
NO pp ESCRI F WOR FEE
PUB�IT:SEWER�CONNEttING TO IF S
00
SEPTIC TBSAEENWVK SEEPAGE PIT OR TYPE OF CONNE 10 LENGTH FROM
PITS AND/OR DRAINFIELD 00 T CURB L M L TO P L
OVERFLOW SE PAGE PIT DRAINFIELD
C R
HOUSE SEWER CONNECTI 6 TO
RIMNA �I T YST S CO IVP NO JOB NO
MOR[TO XOU9EIS NALIt BLDG OR TRUNK PERMIT NO ROAD PERMIT NO 1
A RE PA I R OREAWBEANDON HOUSE STATE ENCROACHMENT
0 D, SYST49 I00 PERMIT NO
INDUSTRIAL
V APPROVAL
CHAR EB
OWNS S PERM T 2 00 CONNECTION CHARGE FEE
ADTHORMATION TOTAL. FEE "d REIMBURSEMENT FEEI RAVE AT THIS DATE A /
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTWITH THE IINGADWKUIMED ONO APPROV DATE I SFOR SSigel"
TO THE PUBLIC SEWER DX--9-9
0
SIGNED THISAY F 1-n4A A + NEW HOUSE SEWER
OWNER OR
Qom.. CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDR SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COYPU CESSPOOL 0 DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAW! REGULATING
PLUMBING AND SEWERS ALTER REPAIR DLIYEA OR
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AMD/OR SEWAGE DCT PLUG
SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PlUO AND
CALIFORNIA OR THAT 1 AN THI�LEGAL OWNER OF TXE ABOVE ABANDON HOUSE SEWER
DESCRIBED REBID ENTI ROf BACKFILLSE CTANKS
SIGNATURE SEEP PIT ! CESSPOOLS
OF PERMI a1�
r
ATION ROBERTA WOOD
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