HomeMy Public PortalAbout6243 SULTANA AVE_Sewer__ -EBOS 3 62
APPLICATION FOR PERMIT
6A642O
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION -U;LD1 NO
AC.DRESS
JOHN A. LAMBIE County Engineer
WILLIAM A. JENS& Supt of Building ---
L D'�'
_R'
[A 7
LOCALITY
A L'
OCALITY 4-
N CA E�S_i:
CROSS ST.
FOR APPLICANT TO FILL IN
LEG L
ION LOT NO OWNER
[I)E 5 C FRIP
MAIL
ADDRESS
2- /
BLOCK TRACT. —
BLOG5.
SIZE OF 1101 N �4 __Y NO.
NOW ON LOT TEL.
USE--OF
------- DISTRICT NO. GROUPMAP
PROCESSED BY
BUILDINGS
BK'L- PG
CONTRACTOR j 7
CONNECTION DATA
ADD
CITY STATION DEPTH
7)5TEL. 11
--t-------------- PC
5TA rC UP R
-,11111-LI:REF-F-111
REGIn-RATION NO. H COUNTY OWER
TYPE OF C�NNECTION LENGTH FROM NO. 71 fflbNi WORK FEE
DUS-E SEWER_ C_0_NNECTI N-G-T"C)-
Y. P.L. M.L.TO P.L.
@
PUBLIC SEWER $5.00
P 0
C.NO.
SEPTIC'TANK.SEEPAGE P17 OR NO,
PITS AND/OR DRArNFIELD @ 57q.00 co.-IMF._NO._____
HOE SEWER CONNECTING TO TWJNK PERMIT NO, ROAD PERMIT NO.
�RIRIVArE DISPOSAL SYSTEM @ S-i.ao
DATE
TNST N 07 IT
CONNECT AD6_m6r4_AL BLDG OF AFFIDAVIT I WAIVED EASE TF
i'.
TO HOUSE SEWER @ $3,00
-X.I-N.,CF.S$POOL.DRYWELL.MANHOLF @ 55.00
HWY.OR ST.WIDENING
t. XL:V A5ANDON HA=iO4-
DISPOSAL SYSTEM. NT___
------ ------
PERMIT NO.
iNDUSTRIAL
WAS iE APPROVAL
CHARGES
ovim PERMIT ------$1 z. 00
Is
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
-----------
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- E IMS
:J FEE
TRACTOR T CONNECT THE ABOVE DESCRIBED LX TINC, DWEL�LING DATE INSPECTOWS SIGNATURE
0 PUBLIC CO P R_ 0__V_AL_S_____
TO THE UBLIC SEWER.
SiGNED THIS--DAY
OWNER OR NEW HOUSE SEWER
OWNERSCONNECT ADDITIONAL
BUILDING OR WORK
ADDRE
SEPTIC TANK,SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR ORAINFiELD
AND
STATE THAT 1HE ABOVE IS CORRECT AND AGREE TO COMPLY
W I T ALL COUNTY ORDINAN F ANO STATE LAWS REGULATING
PLUMSING AND SEWERS CESSPOOL u DRYWELL
SEWAGE DISPOSAL SYSTEM
HERE8- CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER
LI ENSED AS REQUIRED BY I_05 ANGLES COUNTY AND STATE OF'
CALIFORNIA5`N -_
A IFOHN A OR THAT I AM, THE LEGAL OWNER OF, AND JN'tEND TO _DTSC NI4 7 PLUG AND
F E I N. THE ABOVE
DESCRIBED
. ;!OF NTIAL PROPERTY,
1 01 E I N ABANDON HOUSE SEWER
SIGNATURE 1, SACKFILL SEPTIC.TANKS 171
'Rmr-T 4 -2 CESSPOOLS
OF Pr TE�_'
SEE-.PIT(S) L
---)FALIDATION ROBERT A. WOOD
C KSUPERVISING MEC�HAWCAL ENGINEER
. M.0, CASH