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Unified Sewerage agency Ct/�* DATE -'�_---
of Washington Count; CITY OF
OWNER . �'1 _ ���Z --- PHONE
OWNER ' S ADDRESS : _ Z 2, u," ,�.•,i,�`,,.,�..' --
TYPE OF INSTALLATION :
❑ BUILDING SEWER ❑ BUILDING SEWER AND SIDE SEWER
TYPE OF OCCUPANCY :
[] NEW STNGLE FAMTLY [] COMMERCIAL
EXIST. (PRIOR 1-0 7- 1-70 ) ❑ MULT. RES. [] INDUSTRIAL
FIXTURE UNITS---- DWELLING UNIT$
ADDRESS OF STRUCTURE : --
PERMIT CONDITIONS : THE APPLICANT AGREES TO COMPLY WITH ALL `MULES AND
REGULATTONS OF THE UNIFIED SEWERAGE AGE,�CY . WHEN CALLING FOR INSPECTIGN ,
PLEASE REFER TO THE PLRM IT NUMBER . THIS APPLICATION EXPIRES IN ONE-
HUNDRED AND TWENTY ( 120 ) DAYS. THE AMOUNT PAID WILL BE FORFEITED SHOULE
EXPIRATION OCCUR .
FEES . •
PERMIT FEE g � )=bo
CONNECTION CHARGE
SIDE SEWER INSTALLATIO"J -
ISSUED BY
OTHER
TOTAL ------------
- APPLICANT �- DATE.
S`1111'ER PERMIT
ADDRESS OF STRUCTURE
TAX MAP __ TAX LOT _ _ SYSTEM
LOT BLOCK -_.-- OF
APPROVECJ BY DATE — ISSUED BY
REMARKS _. __