HomeMy Public PortalAbout6234 SULTANA AVE_Sewer__ 7$A$l2D APPLICATION FOR PERMIT 1
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DIVISIO14 OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
ADDRESS, -
JOHN A. L.AMBIE,COUNTY ENGINEER -�-----
CASSATT D.GRIFFIN, Sur—T OF BUILDING LOCALITY , 6
NEAREST _,( ✓ /
FOR APPLICANT TO FILL IN CIIOSS ST,�'._:�__
LEGAL
DESCRIPTION LOT N� -OWNER - { ' 1-'
~ MAIL
BLOCK - TRACT ADDRESS
^NO.OF BLDGS, i
T
SIZE OF LOT NOW ON LOT CIY fiEL. N
USE OF _ ' �— DISTRICT NO. GROUP I MAP
BUILDINGS _BK
CONTRACTOR I J _ C ,"�,.s— _ .. I
ADDRESS _ CONNECTION DATA
CITY {: STATION )' Z 43 DEPTH _
+y TEL. NO.CZ-. `ro L 1 v(# - MANHOLE REFERENCE "d7 , " UPPER
STATE
REGISTRATION NO. COUNTY
NO. j DESCRIPTION OF WORK FEE ------- -- --
�'-1 - - - -- — ----- — TYPE OF _TION LENGTH FROM
ROUSE SEWER CONNECTING TO� X.I � i
{ URB% P.L. M.L.TOP.L,
i PUBLIC SEWER----,--_—_@ $3.50__ {
—_-� SEPTIC TANK,SEEPAGE PIT OR -�.-r - --
PITS A_ND,OR_DRAINFIEQ.
_LD _ - $S.00
OVERFL6W SEEPAGE PIT,DRAINFIELD - P.-C. N0. -
EXTN.,CESSPOOL,DRYWELL,MANHOL
. E �, $2.04. CO. IMP. NO. ,✓ JOB N0.
_ _ � .-__..�—�_
HOUSE SEWER CONNECTING 70 ,{
PRIVATE_DISPOSAL SYSTEM Cd $1.00 ! - TRUNK PERMIT N0. ROAD PERMIT NO. - � �✓
1 CONNECTADDITIONAL BLDG.. OR STATE ENCROACHMENT
f{ WORK_T_O HOUSE SEWER - _.---- (u�$1_00 �.__�) _PERMIT N0._ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
-I SEWER OR DISPOSAL SYSTEM — ca-$7.00 I_�__I_ WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PEItI`.4IT 1 DD —--- — ------ — —------- ---------
--- — REIMBURSEMENT FEE
AUTHORIZATION TOTAL y5
1
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN. NAMED CON- APPROVALS DATE IN SPECTOP SSIGNATURE_._.._ !
TRACTOP. TO CONNECT THE ABOVE DESCRIBED EXISTING DWELU NC,
TO THE PUBLIC SEWER. NEIN HOUSE SEWER {
SIGNED THIS-.--.DAY OF_ i9 _ --ADDITIONAL -- - t -�-- -
CONNECT ADDI7JONAI. i'
OWNER GRj j- SU[LDINf OR iVOIiY. !
OWNERS AGENT Yy �-'U SEPTIC TAN[i,SEEP,PIT(S) �—
,ADDRESS__ AND/OR DRAINF E D
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION C£SSPOGLi) DRYWE.LL❑ �
AND STATE 7H.�f THE ABGVE IS CORRECT AND AGREE TO COMPLY
WITH AND STATE LAWS REGULATING ALTER.REPAIR,SEWER OR
PLU ALL COUNTY ORDINANCES HE AND SEWERS. DISCONNECT PLUG AND
SEWAGE DISPOSAL SYSTEM
1 HE.EBY CERTIFf TH- [ AM FROP.�RLY REGISTERED ANDIOR
LICENSED AS REC U.IRED Y LOS ANGRY, COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR TH, 1 ,4M TF F L,:C'. OWNER OF THE ABOVE - - - - ---- - --_ -- —___
DESCRIBED REST. E. 1 L PRGPERT °` BACKFILL SEPTIC TANKS[:
r,.. SEEP PITS) C CESSPOOLS,
.SIGNATURE.. -I
OF P E
i
JOHN A. L:AMBIE. , UNTY ENGINEER n VALIDATION ROBERT A.WOOD,CHIEF PLBG. INSPECTOR
FR.0 CABH
S" 2 4. 1 A "mop�i'.5
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