12015 SW 118TH AVENUE�1
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Address&CAI& /
--- -.-- ----- Permik No._ _y�__.
Name of Occupant____ Permit charge
Connection fee
--- Paid by
Date connected
Type of Building _ Inspection fee
Service Hate_ _ Paid by Date
Contractor - -�- Assessment----- Paid
Size of connection
AIS !� It � � � '� AI►
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PERMIT TO CONNECT
Tigard Sanitary District p o
N
;,
PERMIT N? 915 DA rE
PERMIT IS GIVEN TO
OF
TO CONNECT A
TO THE SYSTEM OF TIGARD SANITARY DISTRICT '
AT
THIS PERMIT MUST BE POSTED ON THE DESCRIBED PREMISES UNTIL CON-
NECTION IS MADE AND INSPECTION OF CONNECTION' HAS BEEN COM-
PLETED.
P11%,','VT FEE PAID $._ ............................TIGARD SANITARY DISTRICT
BY
CONNECTION INSPECTED AND APPROVED
Date Superintendent