HomeMy Public PortalAbout5334 SULTANA AVE_Sewer__ aaa as
ago APPLICATION FOR PERMIT 1
DIMON OF BUIUMI TG AND SAFM SEWER--SEWAGE DISPOSAL
Depar mane of
00m of Loe ABQsIu Coach HaeIMBE
BUILDING
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M J.FOX. COUNTY ENOINRR ADDRESS
CARSATT O GRIFFIN,GD TOFBUILOINQ LOCALITY " Vi C / /
FOR APPLICANT TO FML IN cnosRESTsr L l F A
DeiGAL
RIPTIOON Lor RO SO• 600 Of- -t ¢ OWNER
BLOB /tom TRAY r r 2 U TAIL / O v
MAILER �/
SIZE OF LOT NOW ON LOTo of S CITY _ �I TEL NO
USE OF
B 1 DING E S DISTRICT NO GROUP YAP
BK PO
CONTRACTOR A (R� LG'
ADDRESS ,3�- I/ -"AIV ��}-[j�Z/� r CONM=ON DATA
CITY R S>� &ItvT TEL NO •S/p ¢- STATION DEPTH
STATEMANHOLE REFERENCE UPPER
REGISTRATION NO ?L,107 COUNTY Q LOWER
NO DESCRIPTION OF WORK FEE
ROUSE SEWER CONNECTING TO TYPE OF CONNECTION' LENGTH FROM O
PUBLIC SEWER S 3 SO .� 0 Y CURB P L Y L TO P L O
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 GO
CONNECT ADDITIONAL BLDG OR P O
WORK TO HOUSE SEWER I DO CO ITP NO I7 JOBC N NI
ALTER OR REPAIRN6 ��s
SEWER OR DISPOSALL SYSTEM 100 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABAHOON SEWERJAND/O
STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS ANO/OR DRAINFIELD 2 00INDUSTRIAL
CESSPOOL•ORYWELL WAST APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
OwNEIrS JUTCONNECTION CHARGE FEE S
$ 0
AUTHORIZATION TOTAL FEE 6 REIMBURSEMENT FEE
I HAVE TRACTORTO DATE CONNECT HEACTED WITH THE ABOVE DESCRBEDNEA I IN STINDWELLING MED Cox APPROVALS /ATE INBP TORS SIGNATURE
TO THE PUBLIC SEWER c
SIGNED THIS DAY F NEW HOUSE SEWER JL
OWNER OR CONNECT ADDITIONAL
OWNERS AGENTBUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OP DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS ION CESSPOOL❑ DRYWELLO
AND STATE THAT THE ABOVE IS CORRECT AND AGREEPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS ING ALTER, REPAIR SEWER OR
PLUMBING AND SEWERS
SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTE /ORLICENSED AS REQUIRED BY LOS ANGELES COUNTY ANOF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AY THE LEGAL OWNER OFOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP PIT 3 CESSPOOLS
OF
PERYITTE
WILLIAM J.FOX.COUNTY E.NIOINEUER VALIDATION R A WOOD, CHIEF F'LBO INSPECTOR
C03553A FEB28 5 10.00ll "3552N FEB28 4 450 in