HomeMy Public PortalAbout6028 SULTANA AVE_Sewer__ '6A 6421D - CE808 - 4/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY �' 'C4
NEARESTFOR APPLICANT TO FILL IN CRDss STao l
LEGAL.
DESCRIPTION LOT NO- OWNER q
MAIL
BLOCK TRACT, � " - ADDRESS„ 'J`l
NO. OF BLDOS. ---_—_ ° - 7
SIZE OF LOT NOW ON LOT CITY TEL. NO (J
USEOF
BUILDINGS ' J + DISTRICT.NO. GR., UP MAP PROCES)rE�O BY
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ADDRESS'. 7C , � CONNECTION DAT__
STATION C- -'q ^� DEPTH
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STATE . /A a '7 CA53 �* p� MANHOLE REFERENC
LICENSE YYrr''l a+ �"'( J{j' LOWER
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NO. DESCRIPTION OF WORK FEE TYPE OF CQNNECTION LENGTH FROM -
HOUSE SEWER CONNECTING TO .O Y- %CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 $7.00 -'
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR QRAINFIELD @ f10.OQ t ♦` �,� CO.IMP, NO.,/� kJOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM f3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEN[NT RECORD.IN57R.NO. DATE }
WORK.TO HOUSE SEWER $3.00 a.
OVERFLOW SEEPAGE PIT.DRAfNF1ELD C7
—_�
EXTN.,CE.SSPOOL.QRYW ELL. $5,00 C)
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING �
___SEWER_OR DISPOSAL SYSTEM $3.00_ STATE O
ENCROACHMENT 1--.-
MANHOLE - $7.00 PERMIT N0 _ LJd
INDUSTRIAL 0-
WASTE
WASTE APPROVAL _ Z
CHARGES
OWNERIT S PERMg0
AUTHORIZATION TOTAL FEE �w7-4 �.- CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE` INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR- NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP,PITS)
I HEREBY ACKNOWLEOGE THAT i HAVE READ THIS APPLICATION AND/OR ORAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
i HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR. E
SEWR OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCRNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RE51 DE IN, THE ABT"/O�V,E/',`j,1ES I D RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE ®- g _
OF PERMITTEE __i�"j
BACKFILL S)SEPTIC TANKS ❑
SEEP.PIT(S) Cl CESSPOOLS ❑
VALIDATION CK. M.0. CASH
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