HomeMy Public PortalAbout5552 SULTANA AVE_Sewer__ CESOesB]sD BE APPLICATION &ORERMIT
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COUNTY OF LOS ANGEL
DEPAHTMECOUNTY ENGINEER OF COUNTYENGINEERSEWER-SEWGE DISPOSAL
WELDING AND SAFETY DMSION FESS
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WOJJAM A IENSEN SuP l of BuJdiDp
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DESCRIPTION LOT MO •SLOCN TRACT
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NO F SLp68 or /
SIM OF LOT NOW ON LOT CITY TEL NO �
or
USi I DISTRICT NO JOROUPI MAP PROCESSED BY
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SK PG
CONTRACTOR) • //(�
ADDRESS D /� ✓ C NNECYION DATA
CITY TEL NO 4 / / STATION DEPTH
.J STATE UPPER
REGISTRATION NO I � G COUNTY MANHOLE P[I[R¢NCH
NO DESCRIPTION OF WORK FCCTYPH OF ION
LOTH FRCIFM
HOUSE SEWER CONNECTING TO Y URB P L M L TO PL
PUBLIC SEWER ® 55W I PC NO
SEPTIC TANK S[EPAOE PIT OR CO IMP NO JOS NO
PITS AND/OR GRAINFIELD LI000
HOUSE SEWER CONNECTING TO TRUNK PERM T NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM 5300
CONNECT ADDITIONAL ... OR
AFIIOAVIT RRi[[ [•[[R[Ili RECORD INS" NO DATE
WORKTO HOUSESCWIR O i]GO
OVERFLOW SEEPAGE PIT GRAINFIELD •••AAA
E%TN CESSPOOL DRYWELL MANHOLES $500
ALTER RIPAIR OR ABANDON HOUSE HWY OR BT WIDENING
SEWER OR DISPOSAL SYSTEM 8 6300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
�{E.p. WASTE APPROVAL
O`..•NE S PERMIT s E DD
CHARGES
CONNECTION CHARGE PEE
AUTHORIZATION I TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN M MSp CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I�A}�T�p
"HIf
TO THE PUBLIC SEWER OVALS DAT INSPECTOR E SIGNATURE
SIGNED THIS DAY OF 18_
OWNER OR NEW HOUSE SEWER / f
OWN["AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HLR6BY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATIOX SEPTIC TANK SEEP PIT 16)
AND 6TAT[ THAT TH[ ABOVE IE CORRECT ANO AORC[ TO COMPLY ANG/OR diA1NFICLp
WITH ALL COUNTY ORpINANC[E AND STATE LAWS
REOULATIN6 /
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELI ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS IRCD BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIP. IA O TH I AM TH6 LED
OWNER OF AND IMENO TO DISCONNECT PLUG AND
RESIDE IN TH AB VC DESLRIBED REBID IAL PROP[ ABANDON HOUSE HEWER
SIONATUR[ BACKF ILL B¢PTIC TAXK6 Cl
OF PERMI SEEP PIT(S) ❑ CLIEPOGIJ
CKOVAMATION ROBERT A WOOD
M O CASH SUPERVISING MECHANICAL ENGINEER
DU;09 4 1 7-� JAN11 1 0 D 7.00- p
TEMPLE CITY
APPLICATION FOR
SSEIPERMIT
N SEWER-SEWAGE DISPOSAL 1
COIINTY OF LOS AN6E1.ffi
DEPAH7MEN7 OF COUNTY MCCJN S6
MWING AND SAFETY DIVISION BUILDING -
CM T D M'" LOCALITY PIZ
FOH APPLICANT O IN
CR R 8f
LEGAL
DESCRIPTION LOT NO DESCRIPTION LOT NO OWNER
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT MOR ON LOT 1 TEL M
USE OF M
OU
v N.W DISTRICCTTNO GRr MAP p P BY
CONTRACTOR W _
"DREG '3 c4 CONNECIION DASA
CITY TEL NO 6 STATION DEPTH
_ MANHOLE REFERENCE UPPER
REGISTRATION NO LOW
ER
No II DpESCRI W K FEE
PUBLICSEEW ERRCONNECTING TO $1 00
BE ICTBAW SEEPAGE PIT OR TYPE OF CONNECTION GTH FROM
PITS AND OR GRAINFIELD 300 T CURB L
OYERFLCN SEEPAGpp4E RAINFIELD
N USE SEWER CONNECTING TO Po
C NO
P ly /I, T p ATSTL 1 CO IMP NO JOB NO
WORK TO AOU9T10E ALR LD8 OR TRUNK PERMIT NO sloo ROAD PERMIT NO
ABANDON HOUSE STATE ENCROACHMENT
00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNMS PERMIT p DD CONNECTION CHARGE FEZ
AUMOMATION TOTAL FEE y ✓ REIMBURSEMENT FSE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLINGAMOV DATE INSPECTOR SSIGNATURE
TO THE PUBLIC 39NER
SIGNED THI AY OF B NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGERT-BUILOIN0 0R WORKOR WORK
ADDRESS O AND OR DRAINFEELD (S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE BEAD THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING ANO SEWERS ALTER REPAIR
DISPOSEWEAL RTEY
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/00.
LICENSED AS REQUIRED BY LOS ANGELES COU TV AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AN THE LEGAL OWN OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPER BACKFILL BEI
TANKS
SIGNATURE SEEP PIT 9 CEB POOLB !CG
OF PERNI 7
m. ��/ALa Q. SUPERVLaIHO MMC AMCCAALL WOOD
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