11785 SW 79TH AVENUE-1 11785 8W 79TH AVENUE --
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Address lI ?kj '!AV4 , Permit No,, 7
Permit charge
Owner �Qi�,�,,� `Yy, , Connection feed v
Paid by
Type of building �� L Date connected
Service rate d Inapoction fee •ZSr
Contractor NaSd by date
Size of connection V" aaeeaement paid
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City of Tigard
INSPECTION REQUEST
for
SPECTION TIME: PERMIT NO. :—
DATE: J I-401 -7V DATE ISSUED :
INERS NAMI. ; neo rrt, r�
A D D R E S .
)NTRACTO R : _� �7 x v e*,ev _--
d
.ST . Air Lj, Woterp , Visual, Laboratory p
SUL.T . Aporoved ( , Disapproved 0 , Pendi1 U Lj
CETCI''
INSPECTOR DATE
?E . Attoch supplemental test dato hereto]
_)- Y" ,} i.. ,,r
UNIFIED SEWERAGE AGENCY NO.
WASH fi NGTON COUNTY DATE
CITY OF---- T fta rd
APPLICAT]Ofd F-OR .§WER CONNECTION . PERMIT
OV IN E R: __-Howard 0aleziaoa----------- ---- --- ------._�_—_-----
OWNER'S ADDRESS: 11TA!_�S_u_ 79th ua-*-------------.-------
STREET
CITY
BUILDING SITE: LOT— _ BLOCK —__—.._____.__ ADDITION -------..x,�i�.p�,i__�„�.�a
TAX LOT N0. TYPE OF OCCUPANCY ,
' DWELLING UNITS 1__ FIXTURE UNITS
I SURCHARGE IF APPLICABLE___
i PERMIT FEE INSPECTION FEE ,;;`— TOTAL DEPOSITED__
' (NEW) ( XISTING) BUILDING SEWER SYSTEM
The Applicant agrees to comply with all rules and ,egulations of the Unified Sewerege Agency.
i• APPLICANT
i 1
SEvVER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM.
LINE SIZE 4� INSTALLER ___ Modarn Plumbing
RECEIVED BY____
1 ENCY 011 ItS AGENT)
COMMENTS:—
This Application and permit expires in ninety (80) dans. The amount paid will t)E f, Ieilt'fl
should expiration occur.