HomeMy Public PortalAbout6272 SULTANA AVE_Sewer__ 76AS420
S E-663 42.x'4APPLICATION FOR PERMIT
DIVISION OF BUILDING AM SAFEff SEWER-SEWAGE DISPOSAL
Deportment of County Enq�eer
County of Los Angel. BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D.GRIFFIN,SUP'Y OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEARESTv,
CROSS ST.
LEGAL
DESCRIPTION LOT NO.
4 OWNER
Z
BLOCK TRACT
AIL ✓ 57
c-4
ADDRESS
NO.OF BLDGS. -7
SIZE or LOT 4�
NOW ON LOT
CIT TEL. NO��,��
USE OF
HUILDINGSt f�
DISTRICT NO. I�ROUP BK MAP PG
CONTRACTOR 7-777,!7 ,
ADDRESS CONNECTION DATA
CITY STATION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO. COUNTY
TYPE Of COMNECTION LENGTH FROM
NO. DESCRIPTION OF WORK FEE P,L. hl,L.TO P.L.
OUSE-SEWER CONNECTING TO
PUBLIC SEWER S 3G54
TO
!_PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG, OR
NO.
WORK 1-0 HOUSE SEWER 1.00 CO. IMP.NO. JOB.
ALTER OR REPAIR EXISTING
SYSTEM
TRUNK PERMIT NO. ROAD PERmrr NO.
`-- S
DISCONNECT AND ABANDON SEWER 1�00 I
AND/OR DISPOSAL S'YSTEM 1.00 STAT'E ENCROACHMENT
SEPTIC TANK
'IT
SEEPAGE PIT OR
_j PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00
CHARGES
CONNECTION CHARGE 5EV.
OvRm's PERMIT 3 1 00
AUTHORIZATION
TOTAL FEE REIMBURSEMENT FEE
I-
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIG TH 11 NEW HOUSE SEWER
IG
AY OF 19—L-L.
OWNER ORCONNECT ADDITIONAL
AGENTOWNERS AAGENTJILDfNG OR WORK
SEPTIC TANK, SEEP,PIT($)
P
aRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL DRYWELLCI
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE �BANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. SACKFILL SEPTIC TANKS 0
SEEP.PIT(S) El CESSPOOLS
SIGNATURE
OF PERMITTEE
WILLFAM J. FOX,COUNTY ENGINEER VALIDATION
5 5 JUN 4 4.5 r
By B
DEPUTY DEPUTY
BY BY
0 DEPUTY D F JPU TY