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/�(,�l`tibB� ���lV�i .��1 ��(�fl' .?sl� r� Permit No.
....mar
�N y Permit charge
Owner r Connection feu .�
Paid by_ _
T;pe of building � � Date connected
Service rete f.�A�CgjX, Inspection fee
Contractor ' f`? 11 Paid by date
Size of connection '� Aeeenament paid
1187
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UNIFIED SEWERAGE AGENCY 4923
WASHINGTON COUNTY DATE
CITY O F - Ligar d. ------_--- -- - -
APPLICATION FOR SEWER CONNECTION PERMIT
OWNER: --- -- —L.H. Shirle-y - --
OWNER'S ADDRESS: .__ 9b1D__S.LL. -HilLui -L�•
STREET
Tigard—. - --
CITY STATE ZIP
BUILDING SITE: LOT_. fl__-_-- BLOCK ___.___ .,_ ADDITION Barnam ...fluhdiuiiinn
TAX LOT N0. ___—___ - _ _ TYPE OF OCCUPANCY rsaidaaca. ----- -
ADDRESS -- _ --
DWELLING UNITS ----- -- ---- ---- FIXTURE UNITS
SURCHARGE IF APPLICABLE __-- -- ------•-----
PERMIT FEE - 450-- --- INSPECTION FEE _ -25- - TOTAL DEPOSITED
(NEW)'_�,(EXISTING) BUILDING SEWER SYSTEM ._ Tigard - ----The Applicant agrees to comply with all rules and regal•+tions of the Unified Sewerage Agency.
APPLICANT-4_ =_;__ . �—,gw
SEWER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER S'FTEM.
L,NE SIZE _ -- -*it--- INSTALLER
DECEIVED BY /-
1 OENCY OR ITS AGENTI
COMMENTS:
� e� ►.C tA.l- -- '`tcr" --
This Application and permit expires in ninety (90) days. The amount paid will be forfeited
should expiration occur.