11740 SW 98TH AVENUE ,y
..-� 17..740 SW 98TEi AVENUE
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4q'�® _- - ----
UNIFIED SEWERAGE AGENCY , NO. - -._-- -
WASHINGTON COUNTY GATE
CITY ---
APPLICATION FOR SEWER CONNECTION PERMIT 3
I
OWNER: ✓-- --- -0C
OWNER'S ADDRESS: 17 �- STREET
ZIP
CITvADDITION
RUR.DING SITE: LOT__ —__---- BLO -
_ _ _ - -- --- —
I
TAX LOT NO. --- --
T YPE OF OCCUPANCY
ADDRESS _ _�--�
FIXTURE UNITS - ------
-- - -
DWELLING UNITS ----{
SURCHARGE IF APPLICABLE - -
PERMIT FEE -- `��� -- INSPECTION FEE -
TOTAL DEPOSI ED _-- �-----
(NEW) (EXISTING) BUII_I)ING
SEWER SYSTEM __._-- /J�� --
The Applicant agrees to comply with all rules and re7lations of t!ie Unified Sewerage Agency.
8,PPLICANT
SEWER PERMIT
MR
-1F-IIS PERMIT AUTHORIZES CONNECTION TO TF'E SEWS SYSTEM.
el .`/lt �r�•c-z�__
LINE SIZE _-_ INSTALLER
RECEIVED BY--- EW-- -
IA CY Oji ITS AGENT)
COMMENTS: ._-__
--._-____---------
This Application and permit expires in ninety (90) days. The amount paid will be forfeited
should expiration occur.