HomeMy Public PortalAbout5567 SULTANA AVE_Sewer__ 76A.642D -cESOe -I0-7I APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SE AGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY
FOR APPLICANT TO FILL IN N[ARE{T
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DESCRIPTION LOT NO OWNER
MAIL oel
BLOCK TRACT ADDRESS e5z I/
OP tLDOi
SIZE OF LOT W ON LOT CITY TEL NO
UB! OFBUILDINGS DISTRICT NO pROUP MAP ROCfeEED BY
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CONTRACTOR O / — I/ ,
AODRKSS O CONNECTION DATA
CITY TCL NO 4- /— RATION ty Gj D[PTN
STA
LLICENEt NO CyAE{ C-Z MANHOLE REFERENCE •J /�
NO DESCRIPTION OF WORK F[[ TYPE OFCO _ M LENGTH FROM O
HOUSE[EWER CONNECTING TO Y URB PL
ML TOP L
PUBLIC SEWER O $T 00 •C NO
SEPTIC fANK SEEPAGE PIT OR CO IMP NO PC NO
PITS AND/OR GRAINFIELD 0 {1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NOROAD PERMIT NO O
PRIVATE DISPOSAL SYSTEM 0 Sam
CONNECT ADDITIONAL OLDO OR AFFIDAVIT u. LY[tfR RECORD INS" NO D.T[ U
WORN TO Hou Be
SEWER O {]00
OVERFLOW SEEPAGE PIT DRAINFI[LD DC
IIITN
SPOOL DR 0 E900 HWY OR"T WIDENING O
A T P.IR O ANDON HOU 1(LJ
WE R DISPOSAL 0 t]00 6 STATE ENCROACHMENT
MANHOLE 0 {1 00 PERMIT NO 6
INDUSTRIAL N
WASTE APPROVAL Z
OWNER'S PERMIT i 9 00 CHARGES
AUTHORIZATION TOTAL FEE o CONNECTION CHARGE FEE
1HAV[ AT THIS DATE A CONTRACT WITH THE HEREIN HAMM COM REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED !RIOTING DWELLING AlCROVA�
TO THE P SLIC OMER fW7 DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER
OWNERSAOENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
f EPTIC TANK BEEP PIT(S)
I HERESY THAT
TH ABO THAT I HAVE R[ THEE APPLICATION AND/OR GRAINFIELD
.ND STAT[ THAT TN[ ABOVE IS CORRECT TE AWS E COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYW ELL ❑
1 HERESY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS RED U'RED BY LOS ANGLES COU Y AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 M T FOAL O [R F AN NTEHD TO DISCONNECT PLUG AND
RC81DE I.N. TN[ L• ! R ED R[S C •L PR ' .SANOON HOUSE SEWER
SIGNATUA Lin
BACKFILL pEPi1C TANKS ❑
OR P[R MTTTC ♦Tn E[BP L 1G1 [[POOL{
VAMAIIO CK M O CASH
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