HomeMy Public PortalAbout6010 SULTANA AVE_Sewer__ a&E-663 3.594& �E6APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE E�D{�P�SA L
Department of County Engineer
County of Los Angeles BUILDING i.
WM.J. FOX.COUNTY ENGINEER ADDRESS ' �:IL 1 arJMAP
CASSATT D.GRIFFIN,SUPT OF BUIILDING LOCALITY
FOR APPLICANT TO FILL ITT NEAREST
caoss sr.LEGAL $DESCRIPTION LOT NO..,.-j• �- / OWNERBLOCK TRACT ' j MAILfL gADDRESS101 XJJ '-i[ . OF BLDGS.OF LOT _[ N01Y ON LOT CITY ,�- ..>y, a TEL. NO.USE OFDISTRICT N ROUP
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CONTRACTOR /,2,�1i. o`�1,-, 9r.... •°�'����:�,.-'"&;_.__ —� - _
ADDRESS
CONNECTION DATA
_ �a"d�� � '�1,..:.���r�
CITY `, 7FL. NO. '" STATION DEPTH
:NATE MANHOLE REFERENCEU'PI�eR
REGISTRATION NO, � ❑ COUNTY - __ _ .__ �____-_ ____ LOMER
No, — DESCRIPTION OF WORK FEE -- - _- ----
TYPE OFCONNECTION LENGTH FRG 14
HOUSE si ER CONNECTiNG T- YCURB P.L. M,L. TO P L,
__ PUBLIC ScWER (a_ -
HOUSE S DISPOSAL
CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CC'VNE T ADDITIONAL BLDG. OR P. C..NO.
_ WORK TO HOUSE EWER _ 1.00 O. (A4:P. NO. JOB N_3. -i-LL---,-
`L ALTER OR PEPA.IR EXISTING~ - TRUNK PERMIT N0, ROAD PERMIT NO,
- E aER OR DISPOSAL SYS_TEM _—1.00 -
DISCONNECT AND ABANDON SEINER _-STATE ENCROACHMENT-
_! ANDOR DISPOSAL SYS_T_E_M_ 1_00 PERMIT NO,
` SEPTIC TA SEEP ICE P!T OR _- _ - _-INDU.,7RIAL
CESPITAND/0. GRA 4F1'cLD 2.00 — —
CESSPOOL DRYWELL 'A'ASTE APPROVAL
S°ECTAL CONDITIONS ONLY 2.00 CHARGES
F �---"---- CONNECTION CHARGE FEE
OWNER'S PERMIT $i_P 11 00 ------------ -
AUTHORIZATION TOTAL FEE I REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED 11'!TH - HE HEREIN NAMED CON APPROVALS
TRACTOR TO CONNECT THE ABOVE DF.S REED E.XISI.NG DKtLUNG API�IIt VALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC S r.
��� NEW HOUSE SEWER
ED THIS —"-J OF '-'-, - -Sl—
SIGN _'----------
OWNER OR1 _V -i` CONNECT ADDITIONAL T
BUILDING OR WORK
OWNERS AGENT , -''r '"'�Z-- -
SEPTIC TANK,SEEP, PIT(S)
ADDRESS_.__ _ __ _ANDf_OR DRA[!e FIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL Cl DRy'W ELL❑ �..,...
AND STATE THAT THE AUOVE IS CORRECT AND AGR.r TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS RGGULA,T(NG
PL'JM9ING AND SEWERS. ALTER, REPAIR, EVER OR
SEWAGE DISPOSAL YSTEM i
I HEREBY CERTIFY THAT I AIM PROPERLY REGISTERED AND,%OR
LICENSED AS REQUTIED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND i
CALIFORNIA OR THAT I AM THE —ALEGAL OWNER OF THE ABOVE ABNDON Y:OU SEINER
I 71
DESCRIBED RESIDE AL PROPERTY. E, —T
BACKFILL SEPTIC TANKS C
SEEP PIT(S) L0. CESSPOOLS
_.
SIGNATURE:
OF PER
M[T,T
WILLIAM J.FOX, COUNTY ENGINEER VALIDATION R.A.WOOD,CHIEF PLBG. INSPECTOR
I - 4 7u M2 -4 4 .5 ID