12195 SW TIPPITT PLACE 121cj5 SCJ TIPPETT PLACE
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PERMIT CHARGE _._____.._._. nr�9------
0 NW ER CONNECTION FEE
PAID fj Y
TYPE 13 PU ,LDING DATE CONNECTED
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SERVICE RATE ��—_ —___ INSPECTION FEE
CONTRACI JR PAID BYDAT E
SIZE OF CONNECTION _,__
HSSE;SPIENT PAID
39Sa - v7
UNIFIED SEWERAGE AGENCY No.
WASHINGTON COUNTY DATE __ 10-2E3-76
CITY OF Ti and--- -- -- — --- ._ - — ------__-
APPLICA TiON FOR SEWER CONNECTION PERMIT
---Lifin A. LL)ewer
OWNER: _.__ - -- ---- -- - - -- -- __
OWNER'S ADDRESS: — -------
STREET
- -------- -- _---- ----- _ -- - ._._.----------
CITY STATE ZIP
BUILDING SITE: LOT_.---______ BLOCK .-------- ___ ADDITION ,--,-----
Tax
DDITION :___._-__Tax Map 2S1-313(7
TAX LOT NO. _-_ 4 _— TYPE OF OCCUPANCY __ rGsidence
,ADDRESS - 12-..9-5__5W TiPPett Place
DWELLING UNITS.--__ l____...__ ____ FIXTUPE UNITS --
SURCHARGE IF .APPLICABLE -
575. 00 25. 00 600. 00
PERMIT FEE -_ --_ -- -____-- INSPECTION FEE - TOTAL DEPnSITFD
(NFW) (EXISTING) BUILDING SEWER SYSTEM
The Applicant agrees to comply with all rules and regulations of the Unified Sewerage Agency.
APPLICANTs_r
SEWER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM.
LINE SIZE -__ __.. _ _ INSTALLER
REC'EIVEUBY_.___.�'��_�- .__ _.��^_tea -c_, -
(AGENCY OFUITS AGENT)
Plaid Leron Hechts 7150. 00
COMMENI S:_.---.-----_._-___. ------------_- __ ----
This Application and permit expires in one hundred and t ty (120) days.
The amount paid will be forfeited should expiration occur.
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