13430 SW BARNAM DRIVE i
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riddreee /3�:�� ,` 1:1rn �� Permit No.
i
Permit charge
Owner Connection feeYJv
--____-----�-� Paid by l �y�
Type of building _ Oo':e no •ctod
Service rete _ �� _ _ Ineportion fee
Contractor Paid by date
Size of connection �'' Aenosament; paid
A?HAVP" �,r.1�iiE %gRI��I�M.�'Mti?,•e, �,s�i�,;��., ..�q'�, ,'blw
1. 1
UNIFIED SEWERAGE AGENCY NO. ___ 4908.
WASHINGTON COUNTY DATE
CITY OF-- __..I.igarri __ --------- ---- - ---- --__��—_ _.
APPLICATION FOR SEWER ";ONNECTION PERMIT
OWNER: -
----
OWNER'S ADDRESS: --
STREET
.___ Oreg,pn - -- —97223
cITV STATE ZIP
BUILDING SITE. LOT_7__ BLOCK ---- __.__ _ ADDITION _ Burnam Park
TAX IAT NO. --- TYPE 01F- OCCUPANCY _Raaidence __ {
ADDRESS -
DWELLING UNITS--- 1- ------- -- - -- - - FIXTURE UNIT` --
SURCHARGE IF APPLICABLE -- ---- _ -------- -- - --- ----
PERMIT FEE --460 --- --- INSPECTION FEE 25 __ TOTAL DEPOSITED 4'5
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(EXISTING) BUILDING SEWER SYSTEM
The Applicant agrees to comply with all rules and regulations of t Unified Sewerage Agency.
N
i APPLICANT _.__ �
SEWER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM.
LINE SIZE - _-.-.4" ____._-._. INSTALLER ____ C•®• Shirley
RECEIVED BY_:
PGFNF'OR ITS A ENT)
COMMENTS. 1., YA) AL094
This Application and permit expires in ninety (90) days. The amount paid will be forfeited
should expiration occur.