HomeMy Public PortalAbout5635 SULTANA AVE_Sewer__ I 7W
CBat4003 IR APPLICATION- FOR PERMIT
DMSION OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL
Doparlmont of Cooney EalmBT
County of Eoe AngelBB BUADDRESS ILDING ...5_
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' M J FOX. COUNTY ENGINEER
CAOOATT D GRIAIN OUP T OF BUILDING LOCALITY
ROSS
FOR APPLICANT TO FILL IN CT
CROSS ST
LEO AL
DESCRIPTION LOT NO OWNER I '
BLOCK TRACT MAIL r
ADDRESS J
r OF OGS
SIZE OF LOT J WONBI
LOT CI TEL NO
USE OF
BUILDINGS may] ^, DISTRICT NO GROUP - MP-
CONTRACTOR ! 1�II �r� 5 I -r 4 K PG
ADDRESS �`, F0AeAfie CONNECTION DATA
CITY7e TEL NO STATION DEPTH
Q TATE MAN REFERENCE
REGISTRATION NO ift / 07 ❑ COUNTY LOWER
TYPE OF CONNECTI 'LENGTH FROM
NO DESCRIPTION OF WORK FEE r CURB P L M L TO P L
HOUSE SEWER CONNECTING TO Alili
PUBLIC SEWER ® ! 3 SO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CON ECT ADDITIONAL BLDG OR ^ n,^ CO IMP NO JOB NO
WORN TO HOUSE!EWER 100 _,i S11L
ALTER OR REPAIR EKISTING
r SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
01SCONNECT AND ABANDON SEWER STATE ENCROACHMENT
ANO/OR DISPOSAL SYSTEM 100 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
'PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
--
CONNECTION CHARGE FEE
OWNERS PERMIT s OD
AUTHORIZATION I TOTAL. FEE 4100
REIMBURSEMENT FEE
TRATORHAVE TTO CONNE THIS DATE ONTRTHEAABOVECTED WDESCR BED EKITH THE ISNINGNAMED
DWELLING CON APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF19_ NEW HOUSE SEWER
OWNER OR _ CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP,PIT(81
ADDRESS AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 NAVE 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 !EWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA-OR THAT I AN THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
Ducklap RElIpENT L PRO IRTY J_ SEEP LL IIP C TANKS❑
CA�T/,BB' RESI+� X SEEP PITS C`rAM" Le
SIG 'e URE
OF PERtl1TTEE
A4- li
WILLIAM J FOX.COUNTY ENGINimR VALIDATION —jA%";:kAWM 1 4 4�}y0dq e
- DEPUTY
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DEPUTY DEPUTY