HomeMy Public PortalAbout6149 SULTANA AVE_Sewer__ rends sa as
's.Asazn APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BU;LDiNG —
JOHN A. LAMBIE, County Engineer ADDRESS 7 .1/
WILLIAM A. JENSEN, Sup'i of Building �—_
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LOCALITY
N'ARESY
FOR APPLICANT TO FILL IN CROSS ST.
DE."CRI.PTION LOT NO
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..___ OWNER ,�' 4- ✓'L J r rL f' s !s J C Win.
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MAIL
BLOCK TRACE + ADDRESS
NO. OF SLUGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
B CJILOiN S DiSTRIC:T NO. GROUP MAPPL2d�ESS£D BY
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CONTRACTOR `BK PC
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CONNECTION
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CITY J,c9y,1 TEL NOSTATC�P{ DEPTH - -- -
_ _ _ CTATE MAN OLf REFERENCEREGISTRATION N HSOUNTY
LOWCR
NO. .- GE�CRIF'T Ohl OF WORK F E. TYPE�F hNECTION � Li_'NGTH FROM
HOUSE.SEWER CONNECTING TO --- -- - --- -- Y y GT1RB f PJ - L TO P.L.
PUBLIC SEWER -__ 'S>.00T __ .. s� ,A`t�`--- ..�-- t�E� _— __ �`
SEPTIC TANK,5c'.EPA GE PIT OR - -(- _ ,J-` O. '
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PITS ANO/OR DP.AINFIELD @ $10,00 I ----_CO. IMP,NO. JOB NO
OUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL fSTEM @ S5 00
_._-..J _' _._ ._. -_____-_-___
V tV NCCY ADDITIONAL TIUNAL EtL Du O
_ AFFIDAVIT- WAIVER r YASENENT t RECORD INSTR.NO. I DATE
CO
f W RK '0 HOUSE SEWER e@ $3.0-0
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0
OVER LOW SEE P.AC F I7,DRAIN}cL,D I "
EXT+1 CE5 P'1dL,DR rNELL,A+A H.OLE@ yS.Od
_ .._ . __-_-_ H.WY.ORST.WIDENING
� AL,TER,Rr_PA.1 F<GR AIIP.NDON Fi.7US.E_ r--_-- -
SEWER OR D! P05AL SYS?f-;M $3.00-�___--y,,----_ STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
i WASTE APPROVAL
OWNER'S PERMiTCHARGES--- �= -- -- _ ----- -- ------- - ---
___.__—.-- 1 �✓ ___
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ^. I
i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR-YO CONNECT THP_ ABOVE DESCRIBED EXISTING DWELLING ----- yy---y—}-y---- - 7---- - --TO THE PUBLIC E��'1d??. APER®VACS DATE l INSPECTOR SIGNATURE
SIGNECS THIS '"`e-v Dl`,V i)F' ��'� -
OWNEROR ,t`„ r- > NEW HOUSE SEWER
dW NERS AGENT 'f ✓� IT t ',�Z �C �':"`�.-, -._..__ ____�._--__ �___._-_Jr ____-_ __.___- .____-
-�`- -� .-
- .a APPLICATION
CONNECT ADDITIONAL
,�' BUILDING OR WORK
,ADDRESS �.�Z wr - _S -�'"{ SEPTIC TANK.SEEP,PITISS
1 HEREBY ACKNOWLE' rE THAT , HAVE READ THIS — -
AND STATE THAT 7HE ABOVE IS CORRECT AND AGREE TO COMPI.Y; AND/OR OftA1NFIELD I i
VYITH ALL. COUNTY ORDINANCES AND STATE LAWS REGULATING
LU.MB.NG ANO 5:.WERJ CESSPOnL [] DRYWEL,L 0 I
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HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER, REPAIR,SEWER OR �
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF S_WAGF rDISPOSAL SYSTEM �
CA LlCORNIA OR THAT I R TN€. IEGAL OWNER OF AND INTEND TO DISCONNECT PCU( AAdC_--v- -------—1_ --
P SIDE IN, THE ABOVE € .RISED REBID JTIR!_ PROPERTF'. ABANDON HOUSE SEWER
S..GN AT URE
OF ,EIRMITTEE s'' -� SA KFILi SEPTI„TANKS
----"--- -- -- -' SEEP,PIT IS
CII CESSPOOLS
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VALIDATIO T=- ROBERT A. WOOD
` SUPERVISING MCCHANICAL ENGINEER
CK. M.O. CASH
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