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12505 SW BROOKSIDE AVENUE
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--`�� t L�,11.n�Lt.1ZL• Permit No._i�'�
Name of Occupant _ Permit charge
Connection !ee
— -- Paid by
Date connected 1, '«.7:J`
Type of Building _ _ Inspection fee
Service Rate Paid by_ Date
Contractor Assessment—
Size of connection
PER rJT.T To CONNi,i,T
Tigard Sanii.ary District ij , C-z,
00
PERMIT N? DATE
PERMIT IS GIVEN TO
OF
TO CONNE.-T A -�----
TO THE SYSTEM OF TIGARD SANITARY DISTRIr,T
AT
THIS PERMIT MUST BE POSTED ON THE DE4CRIRED PREMISES UNTIL CON-
NECTION IS MADE AND INSPECTION OF CONNECTION HAS BEEN COM-
PLETED.
PERMIT FEE PAIDl.... ....... ....................TIGARD SANITARY DISTRIC'r
(^ -1
^,ONNECTION INSPECTED AND APPROvirm
of J D.
Date SupertntAndent ----- -