12535 SW SUMMER CREST DRIVE-1 1253 SUMMER CREST DRIVE
SEWER PEUNIT
Unified Sewerage Agency DA.1 E
of Washington County C I TY ]f
OWNER : PHONE :f�='=�,_ 7' �✓
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OWNER ' S ADDRESS: --Z,E
TYPE OF INSTALLATION:
[jj BUILDING SEWER ❑ BUILDING SEWER AND SIDE SEWER
TYPE OF OCCUPANCY :
❑ NE,W ❑ SINGLE FAMILY ❑ COMMtF' : IAL
EXIST. (PRIOR TO 7- 1-70 ❑ MULT. RETS. ❑ INDUSTRIAL
FIXTURE UNITS----Z-- DWELLING UNITS
ADDRESS OF STRUCTURE : '1'e--) S f `G� �� y�C'5 7--
WITH
LES
PERMIT CONDITIONS, THE APPLICANT REGULATIONS OF THE UNIFIED SEWERAGE AGQ�ENCYO CWHEN YCALI_IEJGLFURUINSPECTION ,
PLEASE REFER TO THE PERMIT NUMBER . TH'S APPLICATION EXPIRES IN ONE-
HUNDRED AND TWENTY ( 120 ) DAYS. THE AhOUNT PAID WILL BE FORFEITED SHOULD
EXPIRATION OCCUR .
FEES: _
PERMIT FEE
71
CONNECTION CHARGE
SIDE SEWER INSTALLATION
ISSUED BY
OTHER - �~
TOTAL
APPLICANT ^� DATE
SEWER PERMIT
r N° -
ADDRESS OF STRUCTURE `ZX
TAX MAP `/ la . TAX LOT <_�_ _ SYSTEM
L Q T BLOCK O F .
APPROVED BY DATE ISSUED EKY DATE
D .U . ' S -____1 __ REMARKS
Fi`s Fi✓ Nv/ .S/'t/LO 0..' C'A? 1, X