HomeMy Public PortalAbout5627 1/2 SULTANA AVE_Sewer__ *atfox,., APPLICATION FOR PERMIT 1
DIVIMON OF BUII.MG AND SAMY SEWER-SEWAGE DISPOSAL
Dsplatwwt of County Engineer
Canty of Los Angeles BOILOINa 7 �Z!7-2 A U` 7'AN
WM J. FOX. COUNTY ENGINEER ADDRESS
/ CASSATTD GRIFFIN,6U TOF YUtLOING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
C 9 9T
LEGAL O G
DESCRIPTION LOT NO OWNER
BLOCK TRACT MALL
ADDRESS
WO SIZE OF LOT NOW ON LOTS CITY TEL NO
USE OF
BUILDINGS
I DING DISTRICT NO GROUP YAP
SK PG
CONTRACTOR 1
ADDRESS � �r CONNECTION DATA
CITY TEL NO L. STATION DEPTH
Cl STATE MANHOLE REFERENCE UPPER
REGISTRATION NO
O ❑ COUNTY LOWER
NO DESCRfP'TION OF WORK FEE _
ROUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FR69i
PUBLIC SEWER ® 3 SO Y CURB P L Y L TOP L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
COM N ECT ADDITIONAL BLDG OR P C NO
WORK TO HOUSE SEWER 1 00 CO IVP NO JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 100 PERMIT NO
` SEPTIC TANK SEEPAGE PIT OR
1 PITS AND/OR GRAINFIELD 00 INDUSTRIAL
CESSPOOL ORYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY Z 00 CHARGES
CONNECTION CHARGE FEE
O{h�NEH�$ Fl�blli S 1 00
AUTHOBMATION TOTAL FEE REIMBURSEMENT FEE
I HAVE DATECON
TRACTOR T OS CONNECT T CTED EA ABOVE DESCRIBED EXIWITH THE STINGAMED DWELLING APPROVALS DATE INBPECTOR S SIGNATURE
TO THE PUBLIC SEWER _
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR A/�"'� CONNECT OR WORK
OWNERS AGENT SEPTICBUILDIX OR WOR
ADDRESS SEPTIC TANK SEEP PIT(4)
AND/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AY THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEP IC TANKS❑
Qu� SEEP PITS CESSPO LS
SIOB
OFF PERMIERMITTEE _ -
WILLIAM J.FOX.CouNYY ENGINEER VALIDATION R.A WOOD, CHIEF PLIIG INSPECTOR
LlL0 8 970AUG ] 4 3.0 0 In