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:12.190 SW SUMMER STREET
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DATE '. DATE ISSUED :___-L_L._
OWNERS NAME
C O N T R A C T O R - ---- -- --._ ---- I
TEST ' Air ❑, Water ❑ , Visual ❑ , Labc atory ❑
RESULT; Approved '5 Disapproved ❑ , Pending ❑
SKETCH:
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INSPECTOR DATE
LNotF Attoch 3uFplemental gist data heret]
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Unified Sewerage Agency p
of Washington County CITY OF t _ DA fE J I —.
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OWNER : _ 51. 1(44 crwori J_ PHONE G Q_I794'
0W JER ' S ADDRESS : ��1 Q y� Biu ►r►►+�6?�-�' -- __�
TYPE OF INSTALLATION :
N BUILDING SEWER [� BUILDIN3 SEWER AND SIDE SEWER
TYPE OF OCCUPANCY :
NEW P�SINGLE FAMILY F-1 COMMERCIAL
CK EXIST. ( PRIOR TO 7- 1-70 ) ❑ MULT. RFS. 1 [I NDUSTRIAL
FIXTURE UNITS_._ DWELLING UNIrS__L_._.__
ADDRESS OF STRUCTURE : Qtv,,�-e"
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 PERtiIIT NUMBER . THIS APPLICATION EXPIRES IN ONE—
HUNDRED AND TWENTY ( 120 ) DAYS. THE AMOUNT PAID WILL BE FORFEITED SHOULD
EXPIRATION OCCUR .
FEES :
PERMIT FE:_ T
C0NtiECT10N CHARGE
SIDE SEWER INSTALLATION --
ISSUED BY
OTHER -
3;� ,
TOTAL $��
APPLICANT DATE ,
ADDRESS OF STRUCTURE 7 --
TAX MAP I S 3G C P) T A X L 111 --L(O q(-. S Y S 1 E l,l t&I►P ,) .�_
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LOT r7 BLOCK O F Cit bNbMt�-R1dI� f?-r-�a.—
APF0Q 1 D—By DATE ISSUED BY DATE
D . U . ' S L REMARKS ,cl� Gttc [. Pl G�F QQ
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