HomeMy Public PortalAbout5638-5638 1/2 SULTANA AVE_Sewer__ :.Aff:,ago APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
D"artuiewof Coul Engineer
Comly of I" Angdee BUILDING
WM J.FOX, COUNTY ENGIN®! ADDRESS
CAGGATT D.GRIMM, BUTT OF BURRING LOCALITY
FOR APPLICANT TO FELL IN NEAREST �.
CROSS s
LEGAL
DESCRIPTION LOT NO OWNER
BLOCKTRACT MAIL
Ayy / ADDRESS
SIZE o OFA
OF LOT O NOW ON LOTS CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP YAP
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL NO STATION DEPTH
❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO ❑ COUNTY LOWER
No DESCRIPTION OF WORKAgtAe
HOUSE SEWER CONNECTING TO aT4rPOF CONNECTIO LE TH FROM
PUBLIC SEWER •® S S SO Y CURB PL M L TO P L
HOUSE SEWER CONNECTING TO jErz
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR P C NO
WORK TO HOUSE SEWER1 OD CO IMP NO JOB NO
ALTER OR REPAIR EIIISTI NG
SEWER OR DISPOSAL SYSTEM 1 OO TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 STATE STATE PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Z 00 INDUSTRIAL
CESSPOOL•ORYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 200 -WR DES
CONNECTION CHARGE
Q{IYNE$'$ I pEamT S 1 00
AUTHORIZATION TOTAL FEE OQ REIMBURSEMENT FEE
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TRACTORDATEHAVE CONNECT THEDATE AABOVE DESCRIBED BED EXICTED WITH THE STINGA DWELLIED ONG APPROVALS DATE INSPECTOR 8 SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT I��( G BUILDING OR WORK 11 S
SEPTICTANK SEEP PIT(S)
ADDRESS_ AMD/OR DRAINFIELD
I 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 !TATE LAWS REGULATING
PLUMBING AND SEWERS AL.
A�. REPAIR SEWER OR
S `
I HEREBY CERTIFY THAT i AM PROPERLY REGISTERED ANO/OR E DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COO AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AN THE LEGAL MR OF THE ABOY ABANDON HOUSE SEWER
DESCRIBED RESIDENT
IAL PROPERTY BACKFILL S IC TANKS❑
SEEP PIT 6 CESSPOOL!
SIGNATURi
IL
OF PERMITTEE -
WILLIAM J.FOX.COUNTY Emousuam VAMLTION -R A.WOOD, CHIRP PLOD INKrKCTOR
_T49 1 9 51S OCT 2 0 4 2.0 0 m