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City of Tigu rd
1NSPEc"riON REQUESer �� I
for I
'NSPECTION TINIE : /6 -3oPIPERMI+ Nn.
DATE : .__.. DATE I S S U F..D '
OWNERS NAME :-_ . _..
ADDRESS: Ia SO ``lcc.nuvtFiv p
('ONTRACTOR
FEST : Air P water 0 , i
iESULT. Approved ,
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SKETCH:
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JTE. Att-ioh supplemental
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Unified Sewerage AgenLY v ¢ a DATE
of Washington Count
yGIT . OF r __, - 1
✓ OWNER : - -- -- - PHONE
OWNER ' S ADDRESS: g�-
TYPE OF INSTALLATION:
BUILDING SEWER /BUILDING SEWER AND SIDE SEWER
TYPE OF OCCUPANCY:
L� NEW SINGLE FAMILY ❑ COMMERCIAL
EXIST . (PRIOR TO 7- 1-70 ) ❑ MULT. RFS. ❑ TNOUSTRIAL
FIXTURE UNITS /�I- _ DWELLING UNITS
ADDRESS OF STRUCTURE : A�cw� _ ---- - -
PERMIT CONDITIONS : THE APPLICANT AGREES TO COMPLY WITH ALL RULES . AND
REGULATIONS OF THE INIFIED SEWERAGE AGENCY. WHEN CALLING FOR INSPECTION ,
PLEASE REFER TO THE PERMIT NUMBER . THIS APPLICATION EXPIRES IN ONE-
HUNDRED AND TWENTY ( 120 ) DAYS. THE AMOUNT PAID WILT_ BE FORFEITED SHOULD
EXPIRATION ULCUR .
FEES: IV
/�� PERMIT FEt_
< S' CONNECTION CHARGE
SIDE SEWER INSTALLATION _
ISSUED BY
OTHER r -
TO1 AL
-- - - -- APPLICANT DATE
SECWER PERI"Al '
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ADDRESS OF STRUCTURE &*'V R N?
TAX MAP - _ 15( 3 T.`�_ T A X L 0 T 1�" �_ .... _ SYS 1 E M ------_- _
LOT _8 L 0 C K _ _ __- 0 F .�+tig_ 4,-AN'! port-__ _
APPROVED BY DATE ISSUED BY �AJTE_. n
REMARKS F,�_�
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