HomeMy Public PortalAbout5414 SULTANA AVE_Sewer__ YaAPPLICATION FOR PERMIT
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COUNTY of LOB ANGEM SEWER—SEWAGE DISPOSAL
Mkh'MENT OF COUNTY ENGUOM
BUILDING AND SAFETY DIVMON BUILDING
FORM A. LAM �7 �-w ADDRESS
CASSATT D GRE?PDL Boy L a!Banding LOCALITY IL
OA LICO Fff IN
CROSSNEARST
CST
LEAL
DESCRGI ION LOT NO 499 OWNER
BLOCK TRACT �� MAIL
ADDRESS
NO OF SLOGS
SIZE OF LOT XON ON LOT FGR
TIL NO
USE OF
BUILDINGS YAP PROCL.crn BE �CONTRACTOR ��AOD�TB Z C 01
CONNECTION DATA
CITY TEL NO �'�' DEPTH
REGISTRATION NO COUNTYSTATE UPPER
No DES RI ON 0 R FEE LOWER
HOUSE SEpER CONNECTING TOSPEUBLIC SAEWER ppEE S 00PITSAND/OR DRAEIONN
NFIELDT OR S C710N LENL Y LGTO P L0Y OVERFLOW SEEPAGE PIT�DMINFIELDEXTN CESSPOOL D00
RTWELL VAN HOLE S 00HOUSE SEWER CONNECTING TO PCNO
PRIVATE DISPOSAL SYSTEM 100 JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO/
WORK TO HOUSE SEWER 1 00
ALTER RE IR ORABANDON ROUSE STATE EN RG ENT
SEWER OR DISPOSAL SYSTEM 100 PERMIT NO
IXDUSi[IAL
I E APPROVA
CHARGES
OWNMS pEDUT CONNECTION CHARGE FEE
AUTHOATLATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APYHOVALS DAT[ IRSFE OR S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER
SIGNED THIS AY Ig_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGE BUILDING OR WORK
SEPTIC TANK SEEP,PIT($)
ADD ANGOR nvalw IELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE BEA IS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Cl DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWER! SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY TMT I AN PROPERLY REGISTERED AMD/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AN THE LEGAL OWONOF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED REBID PHO QS BACXFILL9E C TANKS[ISIGNATURE SEEP PITS CESSPOOLS
OF PERMI
®rMMATION ROBERTA WOOD
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C11008 e 0082a as APPLICATION FOR PERMIT -
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COUWY OF LOS ANGELES SEWER-SEWAGE 'DISPOSAL
MUlAyTNM= OF COUNTY ENGDMM _
r B=ING AND SAFETY IDWWON DUD ESNS �X
CASSATTT omw D �,B�of BalkLOCALm
FOR APFUC TO FILL CROS BY
LEGAL
DESCRIPTION LOT NO ORNER
BLOCK TRACT .A _ ` MAIL
�C ADDREB
MO F OG
S1TK OF LOT O NOR OONBLLOTX CITY , NO
USE OF
BUILDING! DISTRICT NO GROUP YAP K / PROCRSSED BY
CONTRACTOR A/I �
ADDRE98 CONNECIION DAT
CRT TEL NO C S S' DEPTH
STATE XOL6 CX PPE
REGISTRATION NO COUNTY
No I DESCRIPTION OF WORK FEE
NUBS C SEWER TO !
00
pEp}IC TANE SEEPA6Q PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DHAINFIE�LD RA F1 �� $300 T CURB P Y L TO P L O
EOVERFLOW
N�CESSPOOL UR PTIVEL°L rANHOLE $100
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM 1 00 CO IMP 0 J0B NO
CONNECT ADDITIONAL BLDG OR
WORK To HOUSE SEWER 1 00 TRUNK PERMIT NO ROAD PERMITPERMITHO
ALT REPA R OR BANDON HOUSE STATE ENCROACHMENT
S OR DI� BA RETE 100 PERMIT NO
INDU L I'
A /Ki
'f Z18
CHARGES
OW=-S PED= 5 2 O0 CONNECTION CHARGE FEE
AUMOFMTION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVAiS DATE INSPECTOR 8 SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER
SIGNED TH AY O IY_ NEW HOUSE SEWER
OWNEROR /y, �n CONNECT ADDITIONAL
OWNERS AGEpT d ` ��F T• � BUILDING OR WORK
ADDRQ� BEC TANK SEEP.
ANPf OR DRAINFIELDflT(e)
1 HERESY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AMD STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRTWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEVERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AN THE L OWNER OF THX ABOVE
DESCRIBED RESIDENTIAL PROP BACKFILL 8 C TANRB❑
SIGNATURE BEEP
PIT
! CESSPOOLS
OF PERYI
iPNj /fYAI�ATION ROBERTA WOOD
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