14230 SW 103RD AVENUE-1 14230 SW 103RD AVENUE
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Unified Sewerage agency _ 0 i 7 _�'
of Washington County CITY OF DATE _ _
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OWNER : ��IrS f rd►v: �- P 10NE
OWNER ' S ADDRESS : _I g Z 3 U �Ca,1 1 0 A,ie
TYPE OF INSTALLATION :
W BUILDING SEWER E] BUILDING SEWER AND SIDE SEWER
TYPE OF OCCUPANCY:
F] NEW SINGLE FAMILY LCOMMERCIAL
N"EX IST. (PRIOR TO 7- 1-70 ) J NLJLT. RES. Ll INDUSTRIAL
I= IXTURE UNIT:j----_,_ DWELLING UNITS I
ADDRESS OF STRUCTURE : _ _kt, 4 __ ---
PERMIT CONDITIONS: THE APPLICANT AGREES TO CO�,iPLY WITH ALL RULES AND
REGULAT ONS OF 1HE lJNIFIED E7WERAGE AGENCY . WHEN CALLING FGR INSPECTION .
PLEASE REFER TO THE PERN11T NUMBER . THIS APPLICATION EXPIRES IN ONE-
HUNnRF'D AND TWENTY ( 120 ) DAYS. THE AMOUf'T PAID WILT_ BE FORFEITED SHOULD
EXPIRATION OCCUR .
FEES :
PERMIT FEE $
CONNECTION CHARGE 3
SIDE SEWER INSTALLATION _
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IS UED BY
OTHER _
TOTAL
APPLICANT DATE
SE-VJER P*E9-Mi"
ADDRESS OF STRUCTURE ��0'J� --_ - — ---- ---- -N?
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TAX MAP ( � �� TAX LOT SYS I
LOT —B L U C _----.—_- _ OF
A7r'—PR-UV ED BYDA1F(� /� r ISSUED-/BY / f DATE
D.U . 'S _ _ REMARKS 1u''?� 4 h�1' ez