11285 SW 92ND AVENUE 11285 SW 92ND AVENUE
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SEWER PERMIT _•;
Uf nfied Sewerage Agency O
of Washington County CITY OF o _ DATE
OWNER : L11IR ---= .---- -----
PHONE :
f
OWNER 'S ADDRESS:
IYPE OF INSTALLATION:
BUILDING SEWER [] BUILDING SEWER AND SIDE SEWER
/TYPE OF OCCUPArlCI':
❑ NEW SINC:.t FAMILY ❑ COMMERCIAL
EXIST. (PRIOF TO 7- 1-70 ) ❑ MULT. RES. [] INDUSTRIAL
FIXTURE UNITS DWELLING UNITS—
ADDRESS OF STRUCTURE : .- A60ve -
PERMIT CONDITIONS: THE APPLICANT AGREES TO COMPLY WITH ALL RULES AND
REGULATIONS OF THE UNIFIED SEWERAGE AGENCY . WHEN CALLING FOR INSPECTION ,
PLEASE REFER TO THE PERMIT NUMBER . THIS APPLICATION EXPIRES IN ONE-
HUNDRED AND TWENTY ( 120 ) SAYS. THE AMOUNT PAID WILL BE FORFEITED SHOULD
EXPIRATION OCCUR .
FEES: _
PERMIT FEE $ ��
CONNECTION CHARGE
SIDE SEWER INSTALLATION
ISSUED BY
OTHER
TOTAL $ 3Z�
------
APPLICANT DATE
SEWER PERMIT
ADDRE_, OF STRUCTURE
TAX MAF' �" ,S _ TAX LOT SYSTEM _
LOT BLOCK OF
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4-
APVOOVED BY DAZE ISSUEDBYDAT1
D. U . ' S _ REMARK 5