11270 SW 92ND AVENUE 11270 SW 92ND AVENUE
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,OTE: Attuch s u i) e in citta( test clot•i J
RECHIPT #8040
Unified Sewe;i9a Agency
of Washington County CITY OF Ti tarrL. D A TF 3 171
OWNER:
Wilburn 0. Slievrnakor PHONE 639-3044
OWNER 'S ADDRESS: - 11270SI4 92nd
TYPE OF INSTALLATION:
D SIDE SEWER LINE TAP AND SIDE SEWER El LINE TAP
TYPE OF OCCUPANCY:
El NFW ❑ EXISTING EJ SINGLE FAMILY [j COMMERCIAL
_x
JEXIST. (PRIOR TO 7-1-70 ) [:IMULT. RES. El INDUS-TRIAL
FIXTURE UNITS DWELLING UNITS I
ADDRESS OF STRUCTURE : 11,27Q 514 92nd
Permit 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 amount paid will be forfeited should expiration occur.
The Agency aous not guarantee the accuracy of the location of side sewer laterals. If the sewer is not located at
the measurement given, the InslaHer shall prospect three feet in all 0i-ectlons frain the distance and depth given.
If not so located, the Installer sliall purchase a 'Tap and Side Sewer' Permit at the current charge and the Agency
will Install a lateral at the location specified by the Installer.
FEES:
PERMIT FEE $ 25-00
CONNECTION CHARGE J2.5-,.00
LINE TAP INSTALLATION B. Roast
OTI11_R ISSUED 13Y
TOTAL
APPLICANT
7' DA Ft.
]IT
RFSZ') OF STRUCTURE PERW 23284
ADD
I 1910 S14 971111
TAX MAP S1_3!jjLjL_ TAX LOT SyS-jEM Fanno
L 0 T --BLOCK OF
APPROVI'D BY DATE ISSUED BY OATL
D. U. - 5 _rrr%1 NAR KS �Ai _Ln_11, j_it1stbe peed and filled