HomeMy Public PortalAbout5644 SULTANA AVE_Sewer__ , 5AR0831254 APPLICATION FOR PERMIT564o-9Wxe 1
DIVISION OF BMWI NG AND SAFETY SEWER SEWAGE DISPOSAL
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County OI Loe Angel" BUILDING
WM J FOX, COUNTY ENGINEER ADDRESS
CAHBATT D GRIFFIN Our T or BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CRO!!ST
LEGAL n
DESCRIPTION LOT NQSb T E / OWNER �Qf4. S
BLOCK TRACT '�/^� /� ADww DLE
S12E OF LOT O NOW F LOTS / CITY ZugTEL NO
USE OF
BUILDINGS DI9TpICT GROUP MAP
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY STATION `� "�' DEPTH
❑ STATE MANHOLE REFER !
REGISTRATION N ❑ COUNTY !R' IV / LOWER
TTPi O�G01 iECTI ON LENGTH FROM
No DESCRIPTION OF WORK FEE r uqB P L M L To P L
HOUSE SEWER CONNECTING TO
PUBLIC SEWER b S 80
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM - 1 00
CONNCO IMP NO
ECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER 100 Q� ��Ci JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 100 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 100 STATE ENCROACHMENT
SEPTIC TANK SEEPAGE PIT OR PERMIT NO
PITS AMD/OR GRAINFIELD 200 INDUSTRIAL
CESSPOOL- ORYWELL —— WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 NQHAR
O �8T s CONNECTION CHARGE FEE
AUTHORMATION I TOTAL. FEE —t REIMBURSEMENT
IHAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSP CTOR S SIGNATURi
TO THE PUBLIC SEW
NEW ROUSE SEWER
SIGNED THI OF 19A �L
OWNER OR .,6S�CL"!•/1, CONNECT ADDITIONAL
OWNERS A6 1ST BUILDING OR WORK
ADDRESS G SEPTAND/10 RTANK PIT(S)
DRA1NFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL(jAND STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 XEpBBT CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AN THE LEGAL R OF THE ABOVE
DESCRIBED RESIDENTIAL P ERTY BACKFILL SIEPBC TANKS❑
SIGNATURE- SEEP PIT(S) CESSPOOLS
oII
r pEn
OF ERYITTEi -
WILLIAM J FOX,COUNTY NGINMRR VALIDATION
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DEPUTY / DEPUTY
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0 DEPUTY DEPUTY