HomeMy Public PortalAbout5836 SULTANA AVE_Sewer__ FOA6420 ,
:Xaoe a.ss APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
IOHN A. LAMBIE, County Engineer
CASSATT A GRIFFIN, Sug't of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL, IN CROSS ST.
LFTGAL
DESCRIPTION LOT NO, _OWNER
BLOCK TRACT MAIL
ADDRESS
NO.OF'YLDGS.
_SIZE_OF LOT NOW ON LOT CITY TBI.. NO,
USE OF
BUILDINGS - - DISi'RICT NO. GROUP MAP i PROCESSED BY
_ BK PG I
CONTRACTOR owl�"--:
ADDRESS CONNECTION DATA
CITY
�-�`� :-TEL.NO. —' STATION DEPTH
ST'ATE MANHOLE REFERENCE
REvISTRATIOw N0. - _ - C: COUNTY LOWER -
LNO, —D'S CP,IPTION OF WORK FEE - – -----..
HOSE SEWER CONNECTING TO
f® PUBLIC SEWER TYPE OF CONNEC'TiGN LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y, CJRB F,L� ML L.TO P.L.___
FITS AND/OR DRAINFIELD $3,00 - . ----
OVERFLOW SEEPAGE PIT,DRAINFIELD
EX..TN..CESSPOOL,DKYWELL r? $2.00
HOUSE SEWER CONNECTING TO P.C.N0.
--PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO, JOB NO.
CONNECT ADDITIONAL BLDG,OR TRUNK PERMIT NO.^ ROAD PERMIT NO.
WORK TO HOUSE SEWER 31.00
ALTER.REPAIR OR DISPOSAL
HOUSE I� STATE ENCROACHMENT
SEWER OR DISPOSAL S1'5TE;M $1.00 PERMIT 140.
YINDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ Z 00 CONNECTION CHARGE FEE
AUTIIOPdZATION TOTAL FEE ! REIMBURSEMENT FEE
I HAVE AT T14, DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE, ABOVE DESCRIBED EXISTING DWELLING APPROVALS I DATE INSPECTOR'S SIGNATURE
'TO THE PUBLIC SEWER.
SIGNED THIS ° .DAY OF _ I9�. NEW HOUSE SEWER
OWNER OR - CONNECT ADDITIONAL
01yN£P,S F.GENT� -- BUILDING OR WORK _
AODR S' _ SEPTIC TANK,SEEP.PIT(5)
-- _= AND/OR DRAINFIELD
I'`.HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION -
AND STATE THAT THE ABOVE,, IS CORRECT AND AGREE TO COMPLY CESSPOOL_0 D_RYWELL ❑ _
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR.SEWER DR
PLUMBING AND SEWERS. SEWAGE REPAIR.
SEPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
-----
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE, OF ABANDON DISCOOUSE NNECT
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS C1
SIGNATURE SEEP, PIT(S) ❑ CESSPOOLS
OF.PERMITTEE
g VALIDATION ROBERT A. WOOD
CK. M.O> CASH SUPERVISING 1AECHANICAL. ENGINEER