12345 SW BROOKSIDE AVENUE I
•
7 •
y
• i
o-.
1
el 44
12345 Slq • , AVENUE
i
f�
AM
Address---_1_L_ COPermit No.
Namc of Occupants Permit charge
Conn ction fee
Paid by
Date connected_$_n?d
Ty;a of B uildir g., XUne% - 0
1 J4 Inspection fee /0- ()
Service Rate Paid byk_/Z& /1,�.____Date
Contractor Assessment --Paid
Size of connection
I
PERMIT TO CONNECT
Tigard Sanitary District
PERMIT No 659 DATE -
PERMIT IS GIVEN TO
OF
TO CONNECT A
TO THE SYSTEM OF TIGARD SANITARY DISTRICT
AT
THIS PERMIT .M IST BE POSTED ON THE DESCRIBED PREMISES UNTII,CON-
NECTION IS MADE AND INSPECTION OF CONNECTION HAS BEEN COM-
PLETED.
PERMIT FEE PAID $..... ..... ................. SANITARY DISTRICT
By -
r.AMAwAd►A.Aw
CONNECTION INSPECTED AND APPROVED
---- Date
i