HomeMy Public PortalAbout6341 SULTANA AVE_Sewer__ 76A 642D APPLICATION. FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL L
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 13U I LOI NG
JOHN A. LAMBIE, COUNTY ENGINEER TNrAREST
ss
COLEMAN W. JENKINS, SUPT. OF BUILDING
ITY
FOR APPLICANT TO FILL IN S 57(PRINT OR TYPE ONLY)
DESCRIPTION L07 NO OWNER IL4 s
MAIL
BLOCK _T TpR�AC`T ADDRESS
NOOF BLDGS.
. d°_ J_
OF LOT NOW ON LOT CITY _ TEL. NO-
SIZE
USE OF
BUILDINGS DISTRICT NO_ GROUP f:LA 55 "AAP PR OCES5ESK
0 8'Y
CONTRACTORfl �rG�F6"K �' ....,i '%J tI✓..- _ y ..
.+s —-
ADDRESS ' ; "� CONNECTIO DATA
g STATION p'' =�.,� -9 DEPTH -�—
CITY r , �" J TEL NO. �' d -
STATE ,y LIC .4v MANHOLE REFERENCE dr --U��-�
LFCF.NSE NO, e� - CLASS b� e /�. ;p� ,'fiLOWER
NO. DESCRIPTION OF WORK - FEE. TYPE OF CONNECTION t LENGTH RD
HOUSE SEVIER CONNECTING TO Y. CURB P L' M.L.TO P.L.
PUBLIC SEWER @ $5.00
P.C.NO.
SEPTIC SAhK.SEEPAGE P1.T
OR 1�
Pt75 AND/OR DRAI NFIELD $10.00. CO.IMP.NO. JOB NO.
HCUSE.5 WER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
I PRIVATE DISPOSAL SYSTEM $3..00 �
CONNECTW AD D.ITIONAL BLDG OR Y AFFIDAVIT I.WAIVER EASEMENT RECORD ISTR N0. DATE O
_.
WORK TO HOUSE SEWER @ $3.00__ I —_ --
OVERFLOSEEPAGE PIT.DRAINFIELD �_— _N-_-
EXTN CESSPOOL.ORYWELL.MANHOLE 0 $5.00 ce
ppe�
I- --- HWY.OR ST.WIDENING
pLSE�R.REPAIR OR A}}AAl®O MJik}ty5E -.J .� 0
_______SEWER OR G*&"SAL SYSTEM @. $3.00 .. _-____ -__._
_� STATE EN C.ROACHM'ENT (e}
PERMIT NO. ILA
SL
INDUSTRIAL
WASTE APPROVAL 7-
CHARGES
OWNERS PERMIT s I '- oo - — ------ --- —
CONNECTION CHARGE FEE
AUTHORIZATION1 TOTAL FEE ---- ---------. --.----- —
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMSURSEMEppNT FEE "��
TRAC TOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC 5EWE>R,l
APP
—APPRAJVALS !INSP EGTOR'S SIGNATURE
DATE
SIGNED THIS AY OF fd' 9 _ --- -"-`--'--" ! _ --_--
OWNER OR JI `f NEW HOUSE SEWER
OWNERS A.G EN.
sy C ONN ECT ADDITIONAL
BUILDING OR WORK
ADDRESS ._.. .1"Y .xy✓_' _ +._ -____I__�' "C"� �_ _
A
/ _-- -�--- SEPTIC TANK SEEP PIT(S} 1
I HEREBY CKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND i OR DRAI.NFIELD 11
AND STATE 'f HAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
UImo,
.PLMBING AND SEWERS. CESSPOOL D DRYWELL
HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR y
TI .-REPAIR.SEWER 0*,
LICEN-ED AS RECUIRED BY LOS ANGLES COUNTY AND STATE OF SE A R15E•�«as SYSTEM -j
CIL IFOR?d IA OR THAT I A LEGAL NER OF. AND INTEND TO -- —`-- - -'"`
RESIDE IN. THE p80VE ES IB RE OEFy7JAL PE R7Y D.SC'ON NE T PLUG AND ,
_ A ABANDON HOUSE EWER
SIGNATURE
rL - _ - (#" BACKFILL SEPTIC TANKS ❑
OF PERMITTEE___ "� SEEP,PIT(5) ❑ CESSPOOLS [}I
;:_ WALIDATION JACK R. ALLEN
I SUPERVISING MECHANICAL ENGINEER
C K.,.�" M.O. CASH
ai Ota aw V 1) .a1 I.1 A rt:f
TION FOR PERMIT` - �
7r$AG4ZV _ APPLICATION SEWER OWN"
���0s
&.1:.663 12.54 �"""� •
DIVISION OF BUILDING AND SAFETY
Department of County Engineer BUILDING
County of LOS Angeles ADDRESS '.
WM.J. FOX, COUNTY ENGINEER LOCALITY E? Ga
CASSATT D.GRIFFIN.SUP"T of BUILDING NEAREST
CROSS r '.Irsa^s` P"0" '•-"'"'
FOR APPLICANT TO FILL IN _
LEGAL �!� � `- +� 0WNERIAj'
_DESCRIPTIONLOT NO MAIL
y R -
BLOCK NN, 3(_3rR S�P, t�J�+1 °v "d .�a11 J y ADDRESS J O .k 7
NO,05 BLDGS- aA.Y . CIT n Pabri � STEL. NO. 6r� )
SiZE_G'„''" Y� 2� N_OW ON•LOT 811S��.w .- MAP
- _ DISTRICT NO. GROUP SK PG
USE OF
_ BUILDINGS Dw A """-•'�__._."'"e`_.,,..�....�.
CONTRACTOR CONNECTION DATA
ADDRESS DEPTH
STATION
TEL. N0. �.f" ct !MANHOLE REFERENCE LOWER_,
CITY .t'�'.-.' U STATE Ii-?S"I_- - - _
"./ :- f;"L- ❑ COUNTY _ LENGTH FROM '
REGISTRATION NO. / --� '� f - TYPE OF CONNECTIOP•L• M.L.
—NO. DESCRIPTION OF'+NORK FEE —
��:_{ HOUSE SEWER CGNNECTING TO $ 3.50
PUBLIC SE`NER
�'--�HjWjSE SEWER CONNECTING TO 1.00 I !•_- JOB. NO.
PRIVATE SP
61OSAL SYSTEM j CO IMP.NO. -- -'
CONNECT ADDITIONAL BLDG. OR 1,00 NO `
"- ROAD PERMIT .
TRUt:K PERMIT N0. ._—�-----'""-'--'
WORK 1'O HOUSE SEWER
—1-- - -- t.Do j
1 ALTEP. OR REPAIR EXISTING _ _ --.-
_+_S_EWER_OR DISPOSAL SYSTEM �----; I STATE ENCROACHMENT
I SCONNECT AND A ANDON SEWER 1.00 1�,-_.__ p.gR_M iT NO.
A
N_D_/OR DISPOSAL SYSTEM -'- INDUSTRIAL
SEPTIC TANK;SEEPAGE PIT OR 2.00 I Imo.._. WASTE P.PPROVAL
PITS AND/ORD ----AINFIELD i` CHARGE____-.-----
—__I ._ ..
—i CESSPOOL-DRYWELL 2.00
SPECIAL CONDITIONS ONLY
"'"— ._ CONNECTION CHARGE FEE
PERMIT � � i% 00
OV ,s
AUTHORIZATION TOTAL FEE _
APPSSOV L� NSFECi OR 5 SIGNATURE
IN NAMED
I HAVETTO COh:NECSO TRACTED ABOVE WITH T BED EXE.STING DW ELLONG __-
TRACTORNEW HOUSE SEWER
TO THE PUBLIC SEWER
SIGNED THIS_DAY OF,.---------""- :ONt+ECT ADDITIONAL
C^�r� SEPTIC TANK
WORK PIT(S)OWNER OR y` '�'. `- gEFT'O TANK,SEEP,PIT(S)
� OYd PdERS AGENT..-.1W.�a•- 1 _ _AN O!OR URAINFiELD
ADDRESS_ _- CESSPOOL❑ DRYWELL❑ _
( HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION --ALTER,
AND STATE THAT THE ABOVE d4 CORRECT AND AGREE E COMPLY SEVtAGE DISPOSAL SYSTEM
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING REPAIR, EWER OR
E1
PLUMBING AND SEWERyg,', DISCONNECT PLUG AND
1 1d FREBY CERTIFY 'LFIA7 1 AM PRCPE LC REGISTERED A.ND/OR ABAh-- -_��N HGUSE:SEWER -
LICENSED AS REQUIRE'[) BY LOS
LEGAL OWNERNGELES OF THEAND AABOVE BACKFILL SEPTIC TANKS❑
CALIFORNIA OR P E P PIT{St [J CESSPOOLS 1.__.,_
DESCRIBED RESIDENTIAL PROPERTY- SEE
f
SIGNATURE -
OF PERMITTEE q�T
COUNTY ENGINEER Ads VALIDATION ,e �'
WILLIAM J. FOX.
BY DEPUTY
BY DEPUTY
BY D,:?UTY
BY - DEPUTY
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