10775 SW PARK STREET 10775 SW PARK STREET
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UN I I-= I F IDI SEWERAGE AGENCY NO. __ 1is20 WASHINGTON COUNTY DATE -----L--2-b--_7 7
CITY OF Tigard
APPLICATION FOR SEWER IOONNECTION PERMIT
01NNER: - ---_--- Carl. Rice
OWNER'S ADDRESS: 10775_ SW Park St.
STREET _-M--
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CITY STATE 21P
BUILDING SITE: LOT_ BLC,LK __ _ ADDITION
TAX LOT NO. _ ___ TYPE OF OCCUPANCY rosidsnra
ADDRESS . 10775 SW Park St.
DWELLING UNI >. FIXTURE UNITS -_
SURCHARGE IF APPLICABLE .-.
PERMIT FEE 3q0• INSPECTION FEE -25• - 1 OTAL DEPOSITED 20219 325.
(NEW) (EXISTING) BUILDING SEWER SYSTEM ___Fenno Cresk
The Applicant agrees to comply with all ruies and regulations of the Unified Sewerage Agency.
APPI. ICANT
SEWER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM.
LINE SIZE INSTALLER
RECEIVED 6Y
(AGENCY OR ITS A NT) t�
COMMENTS: Residence Was existing to prior to 1970
No. Bldg*, permit issued at this time.
-Tliis Application and permit expires in one hundred and twenty (120) days.
The amount paid will be forfeited shr uld expiration occur.