HomeMy Public PortalAbout5530 SULTANA AVE_Sewer__ NKK sites APPLICATION FOR PERMIT 1
DnWON OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Depmhnent of County Englnem
County of LOB Angeles BUILDING
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS
m CASSATTO GRIFFIN SUPTOFSUILDING , LOCALITY �•
FOR APPLICANT TO FILL IN Nc o S SST Lv(
LEGAL OWNER
DESCRIPTION LOT NO
BLOCK JL4A 6� SVAIL
AD.
AODRE99 . �.
NO OF BLDGSCITY TEL NO
SRE OF LOT NOW ON LOT
USE DI Ns6 BK DISTRICT NO GROUP MAP
PG
USE
O
CONTRACTOR
m
ADDRESS 444 F CONNECTION DATA
TEL NO
STATION DEPTH
MANHOLE REFERENCE _ PER
CITY
• ❑ STATE LOWER
REGISTRATION NO ❑ COUNTY
No ' DESCRIPTION OF WORK FEE TYPE OF CONNECTION LE16 OY
HOUSE SEWER CONNECTING TO y CURB P L Y P L
PUBLIC SEWER @ f 3 BO
SEPTIC TANK,SEEPAGE PIT OR _
PITS AND/OR DRAINFIELD ® $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE ® f 2 00 CO IVP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® f t 00 TRUNK PERMIT ROAD PERMIT NO
CONNECT ADDITIONAL SLOG OR STATE ENC➢ ACHMENT
WORK TO HOUSE SEWER ® f 1 00 PERMITJIO
ALTER REPAIR OR ABANDON HOUSE INDPIAL a
SEWER OR DISPOSAL SYSTEM ® f 1 00 E APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S , PEUM s —21- 00
' o0
AUTHORMATION TOTAL FEE d REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWED
SIGNED THIS DAY OF 19— CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK Imo-
OWNERS AGENT SEPTIC TANK SEEP PIT(S)
Y
ADDRESS ANO/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND 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 AN PROPERLY REGISTERED AND/OA AND
DISCONNECT PLUG
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HO PLUGUSE D
CALIFORNIA OR THAT I AY THE LEGAL OWNER OF THE ABOVE
ER
DESCRIBED REBID TI PROPERTY BBACPKFIL (gEPT❑I CESSPOOLS O❑
SIGNATURE
OF PERYITTE 11�'j 0 ,
JOHN A LAMBIE COUNTY ENGINEER VALIDATIO ROBERT A WOOD CHIEF PLBG INSPECTOR
U144 t 4 4 7 3X51' DEC AN 4 2.0 0 R