11000 SW 121ST AVENUE-1 1.1000 SW 121ST AVENUE
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SEWER PERMIT NV �iq
U. aSewerageAgency
of Washington County
,1 . CITY OF _ [_lA-I F jl,,mV—
0 W N E R . W/ ri Y�-g PHONE
OWNER 'S ADDRESS: Itne �Id) (�.Ic . �be . ---- -- --
TYPE OF INSTALLATION-
SIDE SEWER ❑ LINE TAP AND SIDE. SEWER ❑ LINE TAP
TYPE OF OCCUPANCY:
❑ NEW [_] EXISTING SINGI_i I-AMILY ❑ COMMERCIAL
EXIST . (PRIOR TC'. 7-1 -70 ) ❑ MUL_I . I,ES. ❑ INDUSTRIAL
' 1=IX,TURE UNITS DWE:.LLING UNITS�._____-
ADDRESS OF STRUCTURE : _AWS _ —
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 Apolicatien VAN:: . in one hundred twenty (120)
days. The amaunt paid will be forfeited should expiration occur.
The Agency does not guarantee the accur:r-.y of the location of side sewer laterals. If the sower is not located at
the measurement given, the installer shad prosoect three feet in all r!irections from the distance and depth given.
If not so located, the Installer shall purchase a 'Tap and Side Sevrer' Permit at the current charge and the Agency
will Install a lateral at the location spPrified b/ the installer.
FEES:
• PEAMIT FEE $ 3Op . O�
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CONNECTION CHARGE
LINE TAP INSTALL.AIION
ISSUED BY
OTHER
TOTAL $_^
APP_LI CA, NT -�-Y Y� �- DATE
SEWER PERMIT W < <
ADDRESS OF STRUCTURE _ IL DUB C� IOLA,.
TAX MAP �Z!—! 7�!1I nY I n i &00 SYSTEM
LOT A BLOCK OF
AF'PffOVED BY DATE( �p ISS,UIED BY DATE. r
D. U. Is RENARKS Rt - -�1_II CUcQt`1. 4 '�1L �� eoX,e
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