12450 SW KNOLL DRIVE-1 12450 SW KNOLL DRIVE
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SEWER PERS T
E` Unified Sewerage Agency Q ,p
of Washington County CITY OF- _ DATE _ ( '�O•$�
OWNER : C --��- _ —_---- ----- PHONE : 631 ySso& —
0b N'IiR IS ADDRESS:
TYPE OF INSTALLATION:
SIDE SEWER C] LINE TAP AND SIDE SEWFp ❑ LINE TAP
TYPE OF OCCUPAKY
❑ NEW ❑ EXISTING [ SINGL.E FAMILY ❑ COMMERCIAL
EXIST. (PR10R TO 7- 1-70 ) ❑ MULT. PES. ❑ INDUSTRIAL
FIXTURE UNITS DWE_LLING UNITS
ADDRESS OF STRUCTURE : bOye
Pemlt Conditions: The applicant agrees to comply with all rules and regulations of the Unified Sewerage Agency. �-
When calling for inspection, please refer to the Permit Number. The .Application expires in one hundred twenty (120)
days. The amot nt paid will be forfeited should expiration occur.
The Agency dcA,s not guarantee the accuracy of the location of side sewer Iatorals. if the sewer is not located at
the measi?remant given, the installer st�lll prospect three feet in all directions from the distance -.,id depth given.
1' not so lucated, the installer shall purch�ge a 'Tap and Side Sewer' Permit at the current charge and the Agency
will Install a lateral at the location specified `+v the installer.
FGtJt
PER')IIT FEE $ .4-
CONNECTION
CONNECTION CHARGE ®�
LINE TAP INSTALLATION _
OTHER
,•._ --- !�— ISSUED BY
TOTAL $
APPLICANT-- DATE ----
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ADDRESS OF STRUC-rURE SEWER PERMT 2 -
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TAS( MAP _ TAX LOT bh SY11TEl`1
LOT L—_BLOCK PF
AP OVED qY DATE ISSIJED Bti� - -- -u A T_!
D. U . IS - �— R E b A R K.S f )4de ObA.