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Address X33 �r.N __- Permit No. 91�
Name of Occupant Permit charge
Connection
--- Paid by ---- - ------
-- -- ------------ Date connected
Type of BuildingInspection fee
Scrvice Rate Paid by _- Date
Contractor Assessment Paid
'rise of connection_ PERMIT TO CONNECT
Tigard Sanitary District
PERMIT NV 918 DATE l
PERMIT IS GIVEN 110
OF J .,
TO CONNECT A
TO THE SYSTEM OF TIOARD SANT' ARY DISTRICT
AT 1
THIS PERMIT MUST BE POSTED ON THE DESCRIBED PREMISES UNTIL CON'
NECTAON IS MADE AND INSPIECTION OF CONNECTION HAS BEEN COM.
PLETED.
PERMIT FEE PAID _ _. ..... _ ._ .TIGARD SANITARY DISTRICT
By
A1041
7
CONNEC71ION INSPECTED AND APPROVED
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�11 --Date ____ 94erintendent _