9850 SW PEMBROOK STREET 9850 SW PEMBROOK STREET
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SEWER PERMIT
U w . a
Unified Sewerage Agency �•�
of Washington County C I TY OF DATE _
2
OWNER : PHONE :
OWNER 'S ADDRESS : G�� e _ L-2
�rz ,_—
r'E OF INSTALLATION:
❑ BUILDING SEWER ❑ BUILDING SEWER AND SIDE SEWEfc
TYFE OF OCCUPANCY:
❑ NFW SINGLE FAMILY ❑ COMMERCIAL
EXIST. (PRIOR TO 7- 1-70 ) ❑ MULT. RES. ❑ INDUSTRIAL
FIXTURE UNITS _ DWELLING UNITS
ADDRESS OF STRUCTURE :
PERMIT CONDIKIONS: THE APPLICANT AGREES TO COMPLY WITH ALL RULES . AND
REGULATIONS OF THE UNIFIE'U S- 4ERAGE A_ -NCY. WHEN CALLING FOR INSPECTION ,
PLEASE REFER TO THE PERMIT NU'ARFR . THIS APPLICATION EXPIRES IN ONE-
HUNDRED AND TWENTY ( 120 ) DAYS. THE AMOUNT PAID WILL BE FORFEITED SHOULD
EXPIRATION OCCUR .
FEES: ca
PERMIT FEE $__�
CONNECTION CHARGE ✓ O _
SIDE SEWER INSTALLATIO'J
ISSUED BY
OTHFP
Da
TOTAL $ �
----
APPLICANT DAT..
SEWER PERMIT
ADDRESS OF STRUCTURE rr {�a�� N2
TAX. PIAP � TAX LOT SYSTEM _
LOT -- --BLOCK _ OF
A ,ROVED BY GAfE ISSLf-D BY DATE
D. U. ' c REMARKS ��C�.s�'a- .. � �L,e+�• •Y�