HomeMy Public PortalAbout5614 SULTANA AVE_Sewer__ DEPAILTMENT OF OOVNTY ENOINE M t SEWER—SEWAGE DISPOSAL 1
;,r DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
OOUNTY OF LOS ANOET
WILLIAM J. FOX. COUNTY ENGINEER I ADDREBUILDSINSG
FNEAREST
OR APPLICANT TO FILL IN LOCALITY
BU AGGRESS NG SG IV /y U.L 772t A1/f Aag CROSS ST
LOCALITY T�P� C+f Ty DISTR`T NO SERIAL NO (PyERMIT NO
NEAREST -T� `� 6 1 s
CROSS ST
R EIVED B Raady for IAa0wt100 DATEISSUED
OWNER,�i4-�L/�' -
MAIL USEZONE OCCUPANCY
RES8 -
AOD �/�wrS 4AfCEl6(TEL NO L.3 �-' /`,p
'3 Z:7 _/
CITY UK PO
CONTRACTOR jg;OtPLEK co JFS CO IMP NO 2 ,B
ADDRESS 4x r' /tea n/ T 'e'4 C4,6 PL
- JOB NO
CITY t'(&-STEL NO 4r TRUNK PERMIT NO
REGISTRATION NO ff6COU
9CJ ATE
/ NTY ROAD PERMIT NO
DESCRIPTION LOT 110 nerl.t-q LO T Ise STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT tlINDUSTRIAL
WASTE APPROVAL
SIZE OF LOT/q,� )( ,2 Z y MO ON LOTS �� HAROES
USE OF _..,/�
BUILDINGS JCH...(�Cr CONNECTION CHARGE FEE
NO DEBCR PTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIOSEWER ! 0 300 RECEIPT NO ATE BY
HOUSE SEWER CONN NS TO
PRIVATE DISPOSAL SYSTEM 100
CON NCT ADDITIONAL BLOB ON EXOPTION R CORDED
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTI NO DA BY
SEWER OR DISPOSAL SYSTEM 100
DISCONNECT AND ABANDON SEWER CONNECTION TA
DISCANDO
DISCONNECT
DISPOSALD ABANDON
SYSTEM 100
SEPTIC TANK SEEPAG9 PIT OR
PITS AND OR GRAINFIELD 200 STATION D
OESSPo ELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLEREFEREN
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT s 1 Y CURB P L r L TO P L
AUTHORIZATION I TOTAL FEE M
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR' SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS _ DAY OF _19_ NEW HOUSE SEWER
OWNER OR -_ - CONNECT ADDITIONAL
OWNERS AGENT _ _ _ _ __ _ __ ___ __ BUILDING OR WORK
ADDRESS__ _ _ _ __ _ AND/ORDRAINF ELD EP IT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL 0 ORYWELL 0
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
AND/OR LI EN ED IAS REQUIRETHAT I D BY PROPERLY
ANGELES REGISTERED
DISCONNECT PLUS AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY RACKFILL SEPTIO TANK I�I
SIGNATURE /y_ �� � SEEP PIT(B)0 C[SSPoOLSo
OF PERMITTEE C�
TBAO(YA 000 T/50