HomeMy Public PortalAbout6205 SULTANA AVE_Sewer__ DIMPART EEM OF OOUlffY EnrGngZEB SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFE PERMIT APPLICATION
COUB= OF LOS "GMM
WILLIAM J. FOX, OOUNTY ENCIIN¢¢R ) ADDRESS 411 A407
TR APPLICANT. FILL IN LOCALITYBUILDING „ r
_ NEAES
ADDRESS 12 tJ,IL Z'oUCROSS ST.
NLOCALITY 3 EAREST /3 4 nl �Aq 4 y DISTR�NO. I Ready for Inepeetion pPERMIT NO. c
CROSS ST. B-) (� S /V 1'5/� 6 / J
/� � � i�0 RECEIVED BY /�DAT�E ISSUED BY 'DATE
OWNER —rA4 , v/ 3" �_LJ J"1 d L • AL-7-d�'✓0' —41 �.8:o?a ®.?.�`�f.
MAIL
ADDRESS USE OCCUPANCY BK MAP PO
��� �� r
CITY TEL:NO. t�! QTY 6941_ JE'
CONL gTlPf ornis ssiver Const., COoCO0MP.NO. ;Z
ADDW 7 Cole^rove Ave. ,os No.
I oetlebello TEL.i%rkvietiv 1504 TRUNK PERMIT NO. -- -
RE
LEGAL
1trN"NO. State A. COUNTY ROAD PERMIT N0
.
LEGAL ® STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT N0.
BLOCK TRACT S INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF B DGS.
NOW ON LOT CHARGES
USE OF.
BUILDINGS CCNNECTIO RGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOy„� REIMBURSEMENT FEE
Nn PUBLICSEWER CI $ 3.50_ 3 RECEIPT NO. BY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OREXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
—ALTER OR REPAIR EXISTING NO- I DATE I SY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.60 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION 7.,. Y�/} DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 � MANHOLE REFERENCE
v"" w-b� dam" LOWE
TYPE OF CONNE 10 LENGTH FROM �+
OWNERS PERMIT ; 00 Y.. CURB P.L. M.L.TO P.L. IAT
AUTHORIZATION TOTAL FEE
I HAVE 'THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING T.0 TH9 PUBLIC SEWER
SIGNED THIS_ �'. 19w NEW HOUSE SEWER
OWNER OR _ BUILDING OR WORADDITIOK
OWNERS AGENT.
ADDRESS..._....__. ,aJ�/. SEPTIC TANK,SEEP.PIT(S)
TTS r AND/OR DRAINFIELD
I.HEREBY ACKNOWLEDGE THAT 1 HAVE.READ THIS APPLI- CESSPOOL[]. DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
N1. HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/ LICENSEDOR
STATE OFCAL FORN REQUIRED
o TNA .1 AM THE LEGAL OWN-
ABANDON HOUSE SEWER
ER OF THE ABOV IBE E D NTIAL PROPERTY. BACKFILL SEPTIC TANKS[�
SIGNATURE BEEP.PIT(S)0 CESSPOOLS.[]
OF PERMITTEE.
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