HomeMy Public PortalAbout5632 SULTANA AVE_Sewer__ CEBOAPPLICATION FOR PERMI
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISI5IN
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LOCA
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FOR APPLICANT TO FILLSS ByLEGAL
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DESCRIPTION LOT NO BNER V71 - 6: r
IL
BLOCK TRACT sURESS
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BIIE OF LOT / NOW ON LOTY TEL NO
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BUILDING{ TCT MOGROUPMAPEKCONTRACTOR � �" �/'� LADDRESS ! ' p .Ly- rhCONNECTION DATA
CITY TEL n0 � TIOn O DCrtHIA K RCOIRRATION NOHOL!REFEflEXC! `LICI V OWER
NO DESCRIPTION OF WORK FE! TYPE OF CONNECT IOuN MOTM PROM y
HOUSE SEWER CONNECTING TO Y CURB 146 L M L TO P L
PUBLIC SEWER 55M
SEPTIC TANK SEEPAGE PIT CA PC NO
PITS ANO/OR DRAINFIELD SIOOO CO IMP NO JOB MO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $3w
CONNECT ADDITIONAL SLOG OROO AFFIDAVIT [EIYTT AAtELTET RECORD INSTR NO OAT{
WORK TO HOUSE SEWER 0 53M
OVERFLOW SEEPAGE PIT GRAINFIELD
.[TN CC°iPOOL ORYW[LL MANHOLE Q [S GO
ALTER REPAIR OR ABAMOON HOUSE HWY ORST WIDENIN `II
SEWER OR DISPOSAL SYSTEM 0 [S GO STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OT[)SiL.pLQ p®T�'t s 2 00 CHARGES
AIIMORIZATION T'OT'AL FEE DO CONNECTION CNARO[FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DAT[ INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
ADORES{ BUILDING OR WORK
EPTIC
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/O TANK BEEP PIT(S)
AND STATE THAT THE ABOVE If CORRECT AND AORLE TO COMPLY AND/OR GRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
FLUME ING AND SEWERS CESSPOOL ❑ DRYWCLL ❑
1 HLR!°Y CERTIFY THAT I AM PROPERLY RLOISTERED ANO/OR ALTER RSPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIPORMIA OR THAT AM TH LLOAL OWNER AND INTEND TO DISCONNECT PLUG AND
RE81D! IN THE A. ES S[D R IO[NT AND
ABANDON HOUSE SEWER
SIGNATURE O �� ,vv SACRFILL[[ IC TAMNB ❑
BfiEP PTTIS) CIiSpOOtS
VALIDATION ROBERT A WOOD
M O CASH SUPERVISING MECHANICAL ENGINEER
CK
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TeABAM CESGAPPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
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LOCALITY
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FOR APPLICANT TO I= IN LROSB BT
LEGAL —
DESCRIPTION LOT NO A�c� OWNER CJMAIL
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BLOCK TRACT J ✓�{I� �� ADORES]
NO P SLDO{
913[ OF LO / bW ON LOT CITY TEL NO
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U{[ P OI9TRICT NO GROUP
NDS K FMAP PO 1��KO
B
CONTRACTOR
ADDRESS -7,2 0
(�/ CONNE[[ CTION DATA
CITY "r���TEL NO I� STATION ' DEPTH �l `
STAT[ J UPPER
REGISTRATION N40,5/721, COUNTY MANHOLE P[P[RENC LOWER
No DESCR ION OF WORK FQE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB F L P L
PUBLIC SEWER O $500
SEPTIC TANK SEEPAGE PIT OR P L NO u
PITS AND/OR GRAINFIELD Y fl0 GO CO IMP NO l06 NO
HOUSE SEWER CONNECTING TO TRUN T NO
PRIVATE DISPOSAL SYSTEM 0 3]00
CONNECT ADOITIONALSLDG OR AFFIDAVIT %A • [A[[R[IR CORD IN NO DATE
WORK TO HOUSE SEWER d fJ 00
OVERFLOW SE[PAOEPIT DRAINFIELD
E[TH CESSPOOL DRYW[LL MANHOLE Q 8300
ALT RJ[SPF[R�YRM{MMYMHOU98 �� HWY OR ST
SEWER OM.W{P{Wb{Y{{(Y� @ fJ 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WAST[APPROVAL
CHARGES
OWNER"S pEBMR s z o0
A=ORMATION TOTAL FEE CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH TH[ HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED ESIQTI NG DWELLING }�
TO THE PUBLIC {EWER APPROVALS DAT[ INSPECTOR S BIONATUR(
SIGNED THIS DAY OF 1R_
OWNER OR NEW HOUSE{EWER
OWNERS ADEN r CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION S[FTIC TANK SH[P PIT(S)
AND/OR DRAINFIELD
AND STAT[ THAT THE ABOVE IB CORRECT AND AGR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ ORYWELL ❑
I HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR BEW[ROR
LICENSED AS REQUIRED BY LO{ ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM T LEGAL OWNER NO INTEND TO OINOHNECT PLUG AND
PE{IDE IN THE A°OV i I(tD ID[NT OP[RTY ABANDON HOUSE SEWER
SIGNATURE 1
OF
,"MITTEE BACKPi LL B[PTIC TANKS ❑
SL[P PIT(°) ❑ CESSPOOLS
OVALROBERT A WOOD
M 0
CK M o CASH SUPERVISING MECHANICAL ENGINEER
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