HomeMy Public PortalAbout5509 SULTANA AVE_Sewer__ SOS 06311 EB APPLICATION FOR PERMIT 1
DMSION OF BUnZING AND SAFLrY SEWER—SEWAGE DISPOSAL
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COILntT of loos Angeles /z 7 y AD RES9G V O
JOHN A LAMBIE COUNTY ENGINEER ^_
m C SSATTD GRIFFIN SUPTOFBUILDING LOCALITY (. C
FOR APPLICANT TO FILL IN CEARE ST
LEGAL 0 '.Z� .aO .. n
DESCRIPTION LO N0•/ TH OWNERMAI
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BLOCK TRACT[EFAP/'3 e S Sk .& / /( ADDRESS r- r , " p,_ _
SIZE OF LOT JY d 0 OF BLDGS �{ /� CITY --� „ TEL NO
OW ON LOT //
USE OF
OF
DISTRICT NO GROUP YAP
USE
BK PO
CON TRACTOR /-- /
AD SS ^ CONNECTION DATA If
CI TEL NO
v STATION DEPTH
MANHOLE REFERENCE 39 1
Al
REGISTRATI jlIO /� STATE LOW
(� ! COUNTY
nD DE CRIPTI N OF WORK FEE [I
ROUSE SEWER CONNECTING TO TYPE OFION LENGTH FROY-
PUBLIC SEWER @ s 3 SO CURS Y L TOP L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® 33 00
OVERFLOW SEEPAGE PIT DRAINFIELD CO IMP NO lOB RO
EZTN CESSPOOL DRYWELL,YAHHOLE ® S 2 00 _
PRIVATE DISPOSAL SYSTEM HOUSE SEWER CONNECTING
TO ® $1 00 TRUNK PERMIT NO ROAD PERMIT NO 9oQ6Q
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 100 PERMIT NO
,ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® S 100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PEUM s 1 00
AUTHORIZATION TOTAL FLB ` REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSP TOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EKISTING DWELLING ,
TO THE PUBLIC / NEW HOUSE SEWER
SIGNED THI F v "„ -f� 1D��/-F CONNECT ADDITIONAL
OWNER OR / BUILDING OR WORK
OWNERS AGE ^N. SEPTICTANK SEEP PIT(S)
ADDRESS ✓ AIR AND/OR DRAINFIELD
1 HEREBY ACK OW LEDGE THAT 1 HAVE RElV THIS APPLICATION CESSPOOL❑ DRYWELL❑
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANG LES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM TH AL OWNER OF THE ASOVE
DESCRIBED RESIDENTIA5, ROPElli77 OAACCPKFILL SEPTI CTANKSO
SI GNAT
OF PE ITFEE
JOHN A rE.COUNTY EN IN ER --YALIDATIOROBERT A WOOD CHIEF PLBO INSPEc OR
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