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12275 SW SUMMER STREET 2'/5 SMIMER STREET 51 d w w ca w h N N 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• � [K ' _'1_ dNI bvt- J` f� LA��._