HomeMy Public PortalAbout5619 A & B SULTANA AVE_Sewer__ T6ADR2D
®;°°I� "E' APPLICATION FOR PERMIT
_ SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY,
FOR APPLICANT TO FILL IN DISTRICT NO DRouF .MAr, seD BY
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ADDRESS 1.L0
CONNECTION DATA
LOCALITY v1 1�
NEAREST STATION 'DEPTH
CROSS ST
Y UPPER
MANHOLE REFERENCE 76
OWNER
G TYPO OF CONNOGTION I LENGTH PROM
MAIL ML.TO P L.
ADDRESS CURE PL
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CRY A', Till-NO '�� 7 Co MP NO 1322-- JOBNo
LE AL TRUNK PERMIT NO ROADPERMRNO
DESCRUTION LOT NO
AFFIDAVIT WAIV[R EASEMENT RECORD INSTR NO DATE
FLOCK TRACT
NO OF BLDGS
SIZE OF LOT Op X now ON LOT HWY OR"WIOENING '
USE OP
BUILDINGS STATE ENCROACHMENT
PERMITNO
CONTRACTOR INDUSTRIAL
WASTE APPROVAL
ADDRESS • CHARGEs
CT' TEL NO CONNECTION CHARGE PEE
STATE LIGD
LICENSE NO CLASS
NO DE CRIPT OON FFWORK PER APPROVALS DATE INSPECTORSSIONATUR
HOUSE SEWER CONNECTING TO
PUELIC fEWER
+.� SEPTIC TANK SEEPAGE PIT OR NEW HOUSE SEWER
I PRH AND/OR ORAMFIELDI
CONNECT ADDTONAL
HOUSE SEWER CONNBCTINO TO BUILDING OR WORK
PRIVATE OISPOSALSYSTEM SERIC TANK SEEP PITISI -
CONMECTADORIONALSLDO OR
WORKTOHOUSEHEWNR AND/OR DRAINFIELD + J
OVERFLOW SEEPAG E PR DRAINFIELD CESSPOOL ❑ DRVWHLL❑
EKTN CESfPOOI-ORYWELL.MANHOLE '
ALTER REPAIRORABANDON HOUSE ALTERREPAIR SEWEROR
SEWER OR DUIPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DIS ONNECTPLLIGAND "' _•- -� -��
ABANDON HOUSE SEWER
EACKFD.L HEPTXi TANKS
OWNER'S - `
-Permit S SEEP PITIfI❑ CESSPOOLS❑
1 I
AUTHORIZATION' TOTAL FEE r AI! p VALID4TION
I HAVE AT THIN DATE A CONTRACT WITH THE HERIIN NIM CON �'' -
ron iorueo�oN WE^ 0 ABOVE
DEECRISOO� 6 9 8 7 A
810NHD THIS DAY 9� - y/ -
oWNEROR N f E E E O
OWNERS AGENT O
ADUREes - - ,G E - 1 a O oo
THAT I
AND STA S AT THE E O EIS CORRECT AND AORIE6 TO COAMPLY '" • E f 1"a O V V
WITH ALL COUNTY ORDINANCES AND STATE LAWS RIGULATINQ
PW YBINGANDISSWRIRSI
HERSEY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR - I O O-2—7.9
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNUI ORTH"F��Hff�O�O�IROF ANDINTBNOTORE
SON IN THE ABOVEU-PROPERTY
SIGNATURE - ' -
OPPERMRTC6