12275 SW SUMMER STREET 2'/5 SMIMER STREET
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SEVVER PEEMIT
Unif ied Sevierage Agency �r
of Washington County CITY OF DATE ) Z
OWNER: ` Q _ PHONE : .3q- ro�
OWNER 'S ADDRESS: ( �-2�J SW �°'�VA 3+'— _
TYPE. OFF INSTALLATION:
W SIDE SEWER ❑ LINE 'TAP AND SIDE SOWER ❑ LINE TAP
TYPE_ OF OCCUPANCY:
❑ NEW ❑ E'ISTING 9SINGLE FAMILY [] COMMERCIAL
EX ISI . (PRIOR TO 7- 1- 70 ) ❑ MOLT. RES. INDUSTRIAL
FIXTURE UNITS DWELLING UNITS_0A2_r,,
ADDRESS OF STRUCTURE : bOtiit �.
Permit Conditions: The applicant agrees to comply with all rules and regulatioos of the Unified Sewerage Agency,
When calling for Inspection, please refer Ir.) the Permit Number. The Application expires in one hundred twenty (120)
days. The amount paid will be i;,.-felted shoed e;;,+ration occur.
The Agency does not guarantee the accuracy of the location of side sewer laterals. If the sewer is not located at
the measurement given, the Installer shall prospect three feet in all d?rections from the distance and depth given.
If not so located, the Installer shall puichata a 'Tap and aide Sewer' Permit at the current charge and the Agency
will install a lateral at the Ic-ation specitieJ by the installer.
' FEES:
PERMIT FCE
CONNECTION CHARGE
LINE TAP INSTALL iJION
ISSUED BY
OTHER _
TOTALr-
-- - - -- 1 -2 t - e3
APPLICANT DATE
SEWER PERMIT
ADDRESS OF STRUCTURE I2 UA"VAe4-ell
�
TA,X MAP I S G� TAX I.OT _ � � SYSTEMIC
LOT 81_OCK OF
APPROVED 9Y UATE ISSUED BY DATIe
D.U. 'S _ Vh9. RENARKS 'y1t►A�N.PrIoQ• �
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