HomeMy Public PortalAbout5627 SULTANA AVE_Sewer__ iF/6 FesHAY 'TEMPLE CITY
moa ' APPLICATION FOR PERMIT -
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL i
DEPARTMENT OF COUNTY ENGINEER
RUMMG AND SAFETY DIV=ON BUILDING
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FOR APPLICANT TO FII.L
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LEGAL
DEBCRIPTIOM LOT NO OWNER Moe, NiGAlIfl IS
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LC NOW ON LOT CITY E
USE OF mmi
BUILDINGS DISTRICT
(NNO GRTUP BK YAP PQ * P OC)t EBBED BY
CONTRACTOR /NIAAI 4i C.OM 1S r ov /I 9=—
ADDRESS
ADDRESS 1312 9 P, C-4pot sT CONNECTION DATA
CITY pF IVOpj;hVTEL NO STATION DEPTH
REGISTRATION NO COUNTY MANHOLE REFERENCE LOWER
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No ID1ggESCRIP ON OF WORK FEE / f'O r�_
PUBLIC E WERRCONNECTING TO S a U
SEPTIC T/,NK SEEPAGE PIT OR TYPE OF CONNECTION LENG FRO■
PITS AND/OR DRAINFIELD S T CURB P L. Y L TO P L
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00
HOUSE SEWER CONNECTING TO P C NO
P TE SAL7 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR u TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER a S1.00 '
A T R REPAI OR ABANDON HOUSE STATE ENCROACHMENT
OR niS SALcp $100 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNM PERMIT E 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT DATEA CONTRACT WITH THE CON-
TRACTOR TO CIONNECT•THE ABOVE DESCRIBED EXISTIINGAMED DWELLING APPROVALS I DATE INSPECTORS SIGMATURK
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19— KEW HOUSE SETTER
OWNER OR CON NECTADDITIONAL
OWNERS AGENT ?A -i ji �'^-_ BUILDING OR WORK
SEPTICTANK
ADDRraa AND/OR DRAINFEIELDPIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ 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 SEWEROR
PLUMBING AND S4THAT
SEWAGE DISPOSAL SYSTEM
I HEREBY CERPROPERLY REGISTERED AXO/OR
LICENSED AS REANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR GAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED REBID SACRFILLSE CTANRS ❑
SIGNATURE SEEP PITS CESSPOOLS
OF PERM
�P ALIDATION ROBERT A WOOD
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