12330 SW KNOLL DRIVE-1 12330 SW KNOLL DRIVE
I
H
a
A
a
a
0
z
C
N
I
n 4`\N LC A P EMT N? 2=0
ti+�` U a
i
unified Sewerage Agency ?�
of Washington County C I 1-Y Of — )ATE
O VI N F R : -----Tvo�h F . A a4i. PHONE :
OIVI FR `3 ADDRESS: I�3 U S IID VKatr"
TYPE OF INSTALLATION:
P(SIDE SEWER n LINE TAP AND SIDE SEWER ❑ LINE TAP
TYPE OF OCCUPANCY:
C� NEW ❑ EXJSTING XSINGLE FAMILY ❑ COMMERCIAL
EXISF . (PRIOR TO i -7n ) ❑ MULT. RES. [I TN , USTRIAL
FIXFURE UNITS_ _ DWEL.LING UNITS._._1____
ADDRESS OF STRUCTURE : -_�A`oov -t
Permit Conditions: The apolicant ,igreLs to comply with all roles and regulations of the Unified Sewerage Agency.
When calling for inspection, i:lease refer to the Permit Number. The Application expires in one hundred twenty (120)
days. The amount paid will be forfeited should expirmion occur.
The Agency does not guarantee the accurFcy of the location of side sewer !ateials, If the sewer is not located at
the measurement given, the instc.-ller shall iroz;pect three feet In art directions from the ("stance and depth liven.
If not so locate-y, the installer shall purch,ise a ' 1 ap and Side Sewer' Permit at the current chane and Vie Agency
will Install a lateral at the location -.pecified by the :-staller.
FEES:
FERMIT FEE
CONNEC i"TGN CHARGE 3s'
LINE TAP INSTALLATION _
ISSUED BY -
0rHEii
'TOTAL $
_ __ --------
APPLICANT --� � DATE -
SEWER PERMIT" N�
A D D R F S S OF STRUCTURE I Z 3 3 0 `5V �/�-_�!_
TAX Mf P _- Sl-� _--- TAX 1_0T 4820 SYSTEM MMG Cn
L 0'T — I 0
-. -_B L.0 C K _ OF
APP0` CU BY DA FF- ISSUED BY
D . U. ' S ____ R E b A R K ST-