12580 SW 68TH PARKWAY .� 12.580 SW 68TH--AaI&b& —
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Add:-Ess ��5�D �' ✓ (�. Permit No.
Permit charge
Owner Y � ' / �L Connection fee
Paid by
Type of building Oate connected 3�G
Service rateI
. ^'
D nspection Fee
Contractor Paid by .__. (late
Size of connection Assessment _ Paid
'3 -9 77
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City of Tigard
N`sSPECTION REQUEST
for
'INSPECTION TIME: "Od PERMIT NO. :
DATE: 12-YZ6 DATE ISSUED : I Z
OWNERS NAME :ADDRESS:
` -------
CONTRACTOR :
TEST : Air Q, Woterm(, Visual ft/ Laboratory []
RESULT: Approved , Disapproved O Pending [3
SKETCH:
3` I
0
INSPFC.TOR DATE
COTE : Attach !uPriementnl T,jet data beret]
UNIFIED SEWERAGE AGENCY NO. 9569
WASHINGTON COUNTY DArE _---- _
CITY
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CITY OF-
APPI.-ICA-1 ION FOR SEWER CONNEC-TION PURMIT
OWN T.R- Aersold D. Maxwell
OWNER'S ADDRFSS: -
Tiyard STREET
!"I FY
BUILDING SITE: tOT BLOCK ADDI TION
TAX LOT NO. TYPE OF OCCUPANCY residencd
ADDRESS ___ 6�th.
.-%-AX-j,2560 S.U.
OWFLLING UNITS FIXTURE UNITS
SURCHARGE IF APPLICARI.E ---
J 1)0. 110 25. 00- 575. 00
PERMIT FEE INSPECTION FEE TOTAL DEPOSITED
(NEW) (EXISTING) BUILDING SEWER SYSI EM ranno Creek -
The Applicant agrees to rumply with all rules and regulations of the Unified Sewerage Agency.
APPLICANTS//`C"
SEWER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM.
LINE SIZE 411 - INSTALLE9
RECEIVED BY �—Jll Y-(AGENCY OR ITS AGU\11)
COMMENTS: . Sower coiinection (j,11Y .-,5. 00 Phi.1 Lrn-jis School
550. 00 Jack A. Ronaroya Agruetnent
This Application and permit expires in ninety (90) days. The amount paid will be forfeited
should expiration occur.