HomeMy Public PortalAbout5633 A, B, C SULTANA AVE_Sewer__ aaK"$.R$ APPLICATION! FOR PERMIT� _
DIVISION OF BUMDIIIG AND SAFETY SEWER—S A E DISPOSAL
Department of County EBglueeX
of ]Ay Angelm BUILDING
WM.J PDX.COUNTY ENGIN[0011 ADDRESS J
CABBATT D GRIFFIN,SUPT OF BURe114e LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS BY
LEGAL p
DESCRIPTION LOT NO 7' 9, f OWNER
BLOCK TRACT MAIL
L/ �L n p ADDRESS J Y J
SIZE OF LOT 97X21, J NO OF DG5 04, / � CI TEL NO /J9/
NO ON OT 7
USE OF If
BUILDINGS, DISTRICT NOV MAF
BK PG
CONTRACTO
ADDRESS/J CONNECTION DATA
CITY TEL NO JvC79fi STATION DEPTH
I ATE MANHOLE REF E! E UPPER
REGISTRATION NO QQ 7 ❑ COUNTY LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE F ONNECTION LENGTH FRO
PUBLIC SEWER ® S S 50 Y CURB P L M L TO P
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
NNECT ADDITIONAL BLDG OR P NO
WORK TO HOUSE SEWER 1 00 CO IMP NO B XO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 100 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON 9EWER STATE ENCROACHYE
AND/OR DISPOSAL SYSTEM I OO PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS ANDDRAINFIELD QD INDUSTRIAL
CESSPOOL-DRYWELL ASTE APPROVAL
SPECIAL CONDITIONS ONLY 200 CHARGE
OviER S CSTCONNECTION CHARGE FEE
S t 00
AUMORMTION TOTAL FEE REIMBURSEMENT FEE
IHAVE TRACTORTO DATE CONNECT THECTED BOVEWITH THE DESCR DESCRIBEDEREIN EXISTINGA DVIEL4 NG APPROVALS DATE INSPECTOR$SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF I9_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
iZ
SEPTIC TANK SEEP PIT(S)
ADDRESS AMD/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ TH19 APPLICATION CESSPOOL(:1DRYWELL[I
ANSTATE THAT THE ABOVE IS C09RECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS SEWER
ALTER, AFFAIR SEW R
EH O
1 HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED AND/OR SEWAGE DISPOSALOR
EM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AY THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPIC TANKS❑
BEEP FRB CESSPOOLS
SIGNATURE
OF PERMITTEE
WILLIAM J.FOX.COUNTY ENGINEOTR VALIDATION R A.WOOD.CHIMP PILING INSPECTOR
JED 5 0 3 6In DEC 12 4 2.0 0 n