11200 SW 115TH AVENUE ■
1.1200 SW 115TH AVENUE
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-_ CON14ECTION FEE S
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TYPE OF BUILDING t ,fit-�-' ------
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UNIFIED SEWERAGE AGENCY NO t0612
WASHINGTON COU N'TY DA I E __AUQUSt 17. 197E
CITY OF-__ -
APPLICATION FOR SEVIER CONNECTION PERMIT
OWNER:
OWNER'S ADDRESS:
STREET
--Tigard - -- — - Oregon _ 97223__-_
CITU STATE ZIP
BUILDING SITE: LOT BLOCK .----_.-_--- ADDI BION
TAX LOT NO. -... _.- TYPE OF OCCUPANCY
ADDRESS +,tj:, ,i 5W 115th _Ave._
DWELLING UNITS FIXTURE UNITS -- - --
SURCHARGE IF APPLICABLE —
PERMIT FEE _l.l-0-0•-00 -- - INSPFCMON f- P 25.10— TOTAL DEPOSITED
(NEW) ,1EXIS1LWQL BUII._DING SEINER SYSTEM ._____ Fanno Creek_.._.._
The Applicant agrees to comply with all rules and regulations of the Unified Sewerage Agency.
APPLICANT
/PERMIT
SEWLR PERMITAUTHORIZES CONNECTION TO THE SEWER SYSTEM.
LINE '"17_E _ INSTALLER
RECEIVED BY_
(AGENCY OR ITS AGENT!
COMMENTS: Leron HF iyhts paid $150. 00 — Sewer Connection only
This Application and permit expires in one h..ndred and twenty (170) days.
The amount paid will be forfeited sh-)uld expiration occur.