HomeMy Public PortalAbout6005 SULTANA AVE_Sewer__ 7GA -66
E•663.9-55APPLICA.TI.ON FOR. PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL 1
Dep=tmlent of County Engineer
County of Los Angeles BUILDING
WM.J.FOX. COUNTY ENGINEER ADDRESS
CASSATT D.GRIFFIN,SUPT of BUILDING n '
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST'. r'' < .✓I. ---
LEGAL
DES CRIPTiONLN
—OT�0. OWNER
MAIL
BLOCK TRACT � I�>� ADDRESS �_�� ✓N, +_��r'fJ> �;r��
nT' NO. OF BLOTS. - ,j ✓
SIZE OF LOT NOW ON LOT CITY
_ '. d- r TEL. NO.
USE OFIF
_$UILDINGS /Z � —v. DISTRICT N0, GROUP r MAP
-- - - ...�r PG
CONTRACTOR �}`s✓; ,c:-',
ADDRESS CONNECTION DATA 9
CITY TEL, NO. STATION DEPTH
Ci STATE MANHOLE REFERENCE -- - ,/ UPPER_
REGISTRATION NO. y(} COUNTY
Iva. `E?ESCRIPTiO[ OF WORK FEE - " ,f
I HOUSE SEK'CR CONNECTING TO --- -- `TYPE O�r.OtiNECTIOY - LENG�kf FROM -
PU$LIC SE'NER _ s-.3..50. I Y• CUP'$, P 1,. h4.,i�_0_P L,
HOUSE SEWER CONNECTI.NG TO --
�J.PRIVATE DISPOSAL SYSTF_,1S -
CONNECT ADDITIONAL BLDG. OR -_ _-.._._ _ P. C. N0,
---WORK TO HOUSE SEINER 1._00 I_ Co. IMP. NO, _ JOB NO.
ALTER OR REPAIR EXISTING `{
SEWER OR DISPOSAL SYSTEM rRUNK PERMIT NO. _- �--------T�^
1_.00 � I -'T �`-I?OAD PERMIT N0.
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DISCONNECT AND ABANDON SEWER - --- --- _y=—. -�---__--__- ---.-.-
__f AND_/OR DISPOSAL SYSTEM 1.00 -�� STATE FNCROA Hf 5NT
PERMIT NO.
f TIC TANK, SEEPAGE PIT OR
--I PITS AND/OR DRAINFIELDt+I �-- _ INDUSTRIAL"
i CESSPOOL- DRYELL WASTE APPROVAL-- ---- - -
__i SPECIAL CONDITIONS ONLY CY.APGES
---- - - _--- -.-._._S CONNECTION CHARGE FEE
OWNER'S PERMIT �(--1 Go -.._— -—--- ---- - --
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEF
I "� ';
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- APPROVALS 9p
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELL114G APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER -
SiGNEE) TH15. r NEW HOUSE SEINER
E)AY OF �,a.., _1 -, --- - -
_ I
OWNER OR
CONNEC ADDITIONAL -
O`NNERS AGENT r' r �>' —$UILDING_OP:WORK
d SEPTI, TANK, SEEP, PIT(S) f
ADDRESS,/ L` AND/OR DRAIN;IELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL 0 UP,YWELL U
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. —ALTER, REPACK,SEWER OR �4
_SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AIVI PROPERLY REGISTERED AND/OR --AL SYST.EN '------
LICENS.ED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR. THAT I AM THE LEGAL OWNER OF THE ABOVE _ABANDON HOUs"E SEWER_
'J'ESCRIBcD .RESIDEN77� P ERTYo BACKFILL SEPTIC TANKS C
:, SEEP. PITS) ❑ CESSPOOLS C1
SIGNATUREOF PERMITTEE
WILLIAM J.FOX.COUNTY ENGiNE6R VALIDATION R.A.WOOD. CHIEF FLOG. INSPECTOR
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