12220 SW SUMMER STREET 12220 SW SUMMER STREET
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No
v__1 Unified Sewerage Agency
of Nashingto County CITY OF _— DATE
OWNER : el 4R4" —. PHONE :
OWtjER ' S ADDRESS : ���r'y r%'''LJ �.�.s++�I►� Q,� �� _ _ ---
TYPE OF INSTALLATION :
0 BUILDING SEWC^ ❑ BUILDING SEWER AND ;IDE SEWER
TYPE C- OCCUPANCY' :
❑ NEW SINGLE FAMILY ❑ COMMERC' IAL
fes! EXIST. (PRIOR TO 7- 1-70 ) ❑ MULT. RES. ❑ INDUSTRIA'._
T� FIXTUitE UNITS _ DWELLI�ii: U lTS___-_
ADDRESS OF STRUCTURE :
PERMIT roNDITIONS: THP APPLICANT AGREES TO COMPLY WITH ALL RULES AND
REGULATIONS OF THE UNIFIED 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 WILL_ BE FORFF_ITED SHOULD
EXPIRATION OCCUR .
FEES:
PERMIT FEE $
:ONHECTION CHARGE _
SIDE SEWER IN TALLATION
ISSUED BY
OTHER CoW
TOTAL �_ 6_.-049
5—
30
APPI_ I CANT DATE
SE-AJER PEW1,11T
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ADDRESS OF STRUCTI'RE /�+u� N
TAX MAP �
- ��-�--- T A x L 0 T �-- '�O b— SYST�:MLOT __ BLOCK OF _�.�,,4•t4r- OKI
APPROVED BY DATE ISSUED BY DATE
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D . U . ' S _ REh1ARKS ___ _ (� -'