HomeMy Public PortalAbout6242 SULTANA AVE_Sewer__ E808 5-E5 ��j
6A 642D APPLICATION FOR PER41T
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F0'
JOHN A. I NIRIF. (Count, F gineel COLEMAN R JENKINS, Supt. of BuildingT , r¢,
F-LE
R APPLICANT TO FILL IN CROSS 5T. —_
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_LOT NO C M O'NNER &/!/b'4 z '- 1"�MAILTRACT ADDRESS NO. OF DGS, Z-2
FMANHOLE
p " _
SIZE OF LOT NOW ON L T— . - � y,ta,,, �(e TEL. NO.
USE OF
BUILDINGS - "-4�o'd'y,�' ? (' NO. GROUP MAP PROCESSED BY
BKPGCONTRACTORADDRESS ; ;. -° CONNECTION DCITY ;'Y"LTEL. NO. % � DEPTHLICENSE v LICENSE ^ _NO. CLASS E REFERENCE�V ;%y 9' L',)NO. DESCRIPTION OF WORK FEEE OF CONNECTION LE TH FROM.��HOUSE SEWER CONNECT NG TO 4� ,... URB P:L. M.L.TO P.L.
PLICSEWER $ 5.00 �..J Via -�--
P.C.NO,
SEPT I�7A Nlt�5€E AGEfr'I�R /`�!j__ OBNO.
PITS AND/OR DRAINFIELD $10.00 NO.�t- =- --
HOUSE SEWER CONNECTING T3 TRUNK PERMIT NO. ROAD PERMIT N01( 3 �/ j V
PRIVATE DISPOSAL SYSTEM = $ 3.00i .,!- L'
GONNEC7 ADDi?-ZONAL BLDG. OR j AFF DAVIT WAIVER EAsEMINT RECORD. INSTR.NO. DATE
W ORI, 70 HOUSE SEWER $ 3.00! O
RE-PP,1RF-G"R AdiSMDON HOUSE ��T
SEWER OR DISPOSAL SYSTEM $ 3.00 1
ezu— HWY. OR ST.WIDENING
aa��PTo.
EXTN.,CESSPOOL, MANHCLE ` $ 5.001 - --- N7
- _--_-_- -__ STATE ENCROA CHMENT
PERCOLATION TEST $ 5.00 PERMIT NO.
INDUSTRIAL
111ASTE APPROVAL
CHARGES
OWNER'S PERMIT --— --__a5 _21 _ ------ -- --
AUTHORIZATION TOTAL FEE —j— - CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ----APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF__ 19._- —
OWNER OR �st 't NEW HOUSE SEWER
OWNERS AGENT -'�'`�' /' 44�[_,t(,.�F'.�' CONNECT ADDITIONAL
~° BUILDING OR WORK }—
ADDRESS + -_ I,a :�"IJ..x-:� .K4s� x_ SEPTIC TANK,SEEP,PIT(S)
! HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY TH A;'E, I AM PROPERLY -91STERED AND/OR ALTER,REPAIR,SEWER OR Y—
LICENSED AS RE.UiR �B`f LOS ANGLr TY AND STATE OF SEWAGE DISPOSAL SYSTEM
.- R OF, AND INT D TO --GALIFORN{A OR THAT I AM THE LE6:4L. DISCONNECT PLUG AND
RESIDE IN, ';'H ABO. DESCRISEip R IAL PPR ERT ggAN DON HOUSE SEWER
t ,
SIGNATURE
OF PER MITT.E ,(Jj BACKFILL SEPTIC TAWKS ❑ /
-"" - ""' -' -- — SEEP,PIIS) ❑ CESSPOOLS -
ALIDATION,
K. M.O. CASH
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