11150 SW 115TH AVENUE-1 U LI U 4-1UUJi Ll i-W.i ii
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. � • SW 115TH AVENUE
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ADDRESS ► - J �� _ PERMIT N0.
PERMIT CHARGE none
CONNECTION FEE
OWNER
_ PAID BY
TYPE OF BUILDING
DATE CONNECTED
/`-;1► INSPECTION FEE
SERVICE RATE ...��. 1. .---------
CONTRACTOR .. ___ PAID BY __ DATE
-----
SIZE OF CONNECTION ASSESSMENT PAID_ . — --- -
S 90 — sv
. S - 17
-6
UNIFIED SEWERAGE AGENCY No. 11007
WASHINGTON COUNTY DATE
CITY U F___ T i c a r d
APPLICATION FOR SEWER CONNECTION PERMIT
OWNER: Mr. & Mrs. Boyd Thornton
OWNER'S ADDRESS: -_.___----_.._. --
STREET
ZIP
CITY
BUILDING SITE: LOT.__ __-_-- BLOCK ___,.--. ADDITION
TAX LOT NO. _-- -__-.-__-- -- TYPE OF OCCUPANCY __ __ _-...__---residEnce- _.
ADDRESS II15I1._.-S.U-.115th-AVr,_ —
DWELLING UNITS ._ _- __-._1_-__—.__-.--..-. -----_ FIXTURE UNITS
SURCHARGE IF APPLICABLE ——
575.00 25. 00 600. 00
PERMIT FEE --.--- INSPECTION FEE _ TOTAL DEPOSITED
(NEW) (EXISTING) BUILDING SEWER SYSTt--M . - Fenno Creek _
The Applicant agrees to comply with all rules and regulations of the Unified Sewerage Agency.
APPLICAINT,�(1'1-1
SEWER PERMIT
t THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM.
LINE SIZE _ - - INSTALLER
RECEIVED BY..-- �AI;EY OR ITS At3tNTI
'�
COMMENTS: Ppid `0. 110 Leron Nei ghts
This Application and permit expires in one hundred Ynd twenty (120) days.
The amount paid will be forfeited should expirmion occur.