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INSPECTION REOUEST
for
i ^INSPECTION TIME : =�) PERMIT NO. : -----
DATE:
O. : f__-
DATE: '(21,492f DATE !SSUED:---,�
OWNERS NAME :
ADDRESS :
CONTI,ACTOR :
TEST'. Air 0, Water p , VisuLaboratory [)
RESULT. A,proved'JJ Disapproval , Pendlnq
SKETCH*
INSPECTOR DATE
" supplemental test dote heret-10
l'
ADDRESS PERMIT NO
PERMIT CHARGE
OWNER �,: ��t' ��)-lc J CONNECTION FEECL�
PAID BY
TYPE OF BUILDING ��c�.,,t � DATE CONNECTED
c,C^UI^E RATE1r . y INSPECTION FEES
CONTRACTOR e lti��._. L PI L � PA 10 �3YDATE�� �-
SIZE OF CONNECTION ___ 2/1 U ASSESSMENT .� PAID __
Id37
UNIFIED SEWERAGE AGENCY N0, 4978
WASHINGTON COUNTY DATE
CITY OF—__
APPLICATION FOR SEWER CONNECTION PERMIT
OWNER:_N',ah i,�.w_ 1�lC I�
OWNER'S ADDRESS: Sl.�.�_. I S
L
-_ - -
(1 4 STREET
t 1\Vl� _-9i
ITV: LCOT
STATE ZIP
BUILDING S -____ _._ BLOCK __--_______ ADDITION
gg
TAX LOT N0. _____ TYPE OF OCCUPANCY
ADDRESS .
DWELLING UNITS FIXTURE UNITS
SURCHARGE IF APPLICABL.E
PERMIT FEE.... 5(SO ____ INSPECTION FEE _S1Y_ TOTAL DEPOSITED ..
(NEW) (EXISTING) BUILDING SEWER SYSTEM ___ fir
The Applicant agrees to comply with all rules and regulations of the Unified Sewerage Agency.
APPLICANT_._— -,�=!!
SEWER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM.
11
LINE SIZE --_____. _----_-__..INSTALLER
RECEIVEDA,"NEENNTI
COMMENTS:_
This Application and permit expires in ninety (90) days. The amount paid will be forfeited
should expiration occur.