HomeMy Public PortalAbout5420 SULTANA AVE_Sewer__ as"'
ca APPLICATION FOR PERMIT
esu •lP COUNTY OF LOS ANGELES �.
SEWER-SEWAGE DISPOSAL
DEPAHTEIENT OF COUNTY ENCUNEES
BUMMG AND SAFETY DTVMON BDILDING
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NEAREST
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FOS CANT TO FILL CROSS n
LEGAL OWNER
DESCRIPTION LOT ND
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MAIL
BLOCK J7 TRACT P ADDRESS O
NO OF SLOGS
9IIE OF LOT •
NOW ON LOT Cl TEL NO
USE OF DISTRICT NO GROUP YAP PROCESSED BY
BUI LDING9
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CONTRACTOR
ADDRESS C - CONNECTION DATA
C TEL NO XtC qaj STATION DEPTH
ATE MANHOLEREFERENCE�/ UPPER
REGISTRATION 0 a COUNTY OWER
No I
pDESCRIgPTI( F WORK FEE
11" PUBLIC EW &CONNECTING TO $S 00
TYPE OFO ECTIONR
SEPTIC T A SEEPAGE PIT OR Y CP L YEL TOP L
PITS AN OR DRAINFIELD 3 00
OVERFLOW SEEPAGE PIT DMINFIELO
D YW@ 12 00
HOU BE
SEWER CONNECTING TO P C NO
pRVATE DA1I�SPO LSYLL EY 100 CO IVP NO I� JOB XO
MORE TO X0�9EI�EYVER LDG OR 0 TRUNK PERMIT NO ROAD PERMIT NO �D
ATR EPAIR OR ABANDON HOUSEdD 100 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
Owmm P®MITy 00 CONNECTION CHARGE FEE
AUTSOFMTION TOTAL FEE REIMBURSEMENT FEEI HAVE AT � / j� Ne
E pzIj��P
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTING A CONTRACT WITH THE HEREIN DWELLING MED I /� �/DWELL
NG LS OVADATE INSPECTOR 9SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGEHT BUILDING OR WORK
ADDRESS sEPT AND/ORTANK SEEP PIT(8)
DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 13 CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE REPAIR
DISPOSEWEAL R OR
1 HEREST CERTIFY THAT 1 AY PROPERLT REGISTERED AND/OR
EM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AN THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED REBID EN IAL PROPERTY BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP PITS CH39P00 LS
or P RMI O
0P VALIDATION ROBERT A WOOD
/D/ ■ 0 CAIM HUPERVISING MECHANICAL ENGIN=R
LACO$ 6 :1 62 IF,nx 31 1 0 A 5.000 P