HomeMy Public PortalAbout6043 SULTANA AVE_Sewer__ t
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BA642B-$9°
ESOS APPLICATION FOR PERMIT
7
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL r..
DESCRIPTION LOT NO,ot 9C _OWNER
BLOCK TRACTs- MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY" >TEL. NO.
USE OF —
BUILDINGS ! ' DISTRICT NO. GROUP- MAP I PROCESSED BY
BK
CONTRACT0P
1�
ADDRESS CONNECTION DATA
CITY a TEL,NO, STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION N0. [j COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING T4
PUBLIC SEWER @ $3.00
SEPTIC TANK,SEEPAGE PDT OR TYAE OF CONNECTION LENGTH FROMY. CURB P.L. M.L.TO P.L.PITS AND/OR DRAINFIELD @ $3.Op
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL.DRYWELL @
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1,00 CO.IMP. NO. JOB N0,
CONNECT ADDITIONAL BLDG,OR
WORK TO HOUSE SEWER TRUNK PERMIT N0. ROAD PERMIT N0.
@ cl;OO ,�.: K
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR bISPp AL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ./' REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED TMS DAY OP T9� NEW HOUSE SEWER
OWNER OR
{ - CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT 'THE.ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER;REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR AND
PLUG
DISCONNECT D
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON DISCONNECT
CALIFORNIA OR THAT -I AM THE LEGAL:OWNER OF THE ABOVE
HOUSE SEWER
DESCRIBED RESIDENT;X1. PROPERTY. - s BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS
OF PER.MITTE
VALIDATION ROBERT A. WOOD
CK, U.0. CASH SUPERVISING MECHANICAL ENGINEER
9 2 5 OG AM23 1 0 D 55.00-