HomeMy Public PortalAbout6228 SULTANA AVE_Sewer__ s s
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sA6420sazn APPLICATION FOR P r RMIT �
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING r
JOHN A, LAMBIE, County Engineer ADDRESS; /! t ,'
WILLIAM A. JENSEN, Supc
Supt of Building LOCALITY .-
NEAREST
FOR APPLICANT TO FML IN CROSS ST. c -")
q B I s
DESCRIIPTION LOT 140. '{ ° `/ OWNER
BLOCK TRACT ? ADDRESS
MAIL
PIO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO
USE OF
BUILDINGS DISTRICT NO. GROU_ MAP PROCESSED BY
1 BK PG_- --
CONTRACTOR
5
LT 1 y-
ADDRESS c CONNECTION DAT' '
CITY " i . TEL.NO. x;- STATION DEPTH
//__ MANHOLE REFERENCE UPPER
REGISTRATION N0. 4�. COUNTY LOWER
NO. I DESCRIPTION OF WORK FEE �
HOUSE SEWER CONNECTING TO 1Y r ,[ L/;
PUBLIC SEWER @ 5;.00 TYPE DF CONNI TdOH LENG H FROM
SEPTIC Tq NK,SEEPAGE PIT OR Y. CURB' P,L, M.L.TO P,L,
PITS AND OR DRAINF'IELD 59.00
OVERFLOW SEEPAGE PIT,DRAINNELD
EXTN..CESSPOOL.DRYWELL Ct $2.00
HOUSE SEWER CONNECTING TO P.C.NO. 0
PRIVATE DISPOSAL SYSTEM SLOO CO.IMP.NO, JOB NO. V
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWERTRUNK PERMIT N0. ROAD PERMIT N0.
t.06
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHklENT
SEWER OR DISPOSALSYSTE C� SLOO PERMIT NO, U
LU
INDUSTRIAL ]a.
WASTE APPROVAL Ul
CHARGES z
OVMR'+S PERMIT 31 21 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I ; `T i ,r ( REIMBURSEMENT FEE
I HAVE AT S 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 THIS DAY O9- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL 11
OWNERS AGENT BUILDING OR WORK i
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS. CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. ALTER,
DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE r` - SEEP.PITIS CESSPOOLS
OF PERMITTEEa >,a
'yALIDATION ROBERT"A. WOOD
H.0. CASH SUPERVISING MECHANICAL ENGINEER