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11660 SW MANZANITA S'T'REET
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REQUEST FOR ACTION
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LOCATION: MCI C,
PROBLEM: -C -—1A
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BY Date: —qjca�l-j
FORWARD TO: Administrator Police
Building Public Works
Library Recorder
P!ar,,ning Other
Department Head Response:
ACTION TAKEN: )iic-
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Forwarded to: State Hwy. Dept.
By: Date
WHITE: To Orginator CANARY: To Dept. Head
Address WO .s a1 Permit No.
Permit charge; o:�
Owner Connection fee
Paid by Az �s�*�-�� „ �o
Type of Building__ Date connected
Service Rate ` - Inspection fee f U'
Contractor �,t,� _� ,,, Paid by, t- r/ e 3
Size of connection y Assessment Paid
__ 1
M.i m E
PERMIT TO CONNECT'
Tigard Sanitary District
PERMIT N° 1092 DATE
PERMIT IS GIVEN TO
OF
TO CONNECT A �
TO THE SYSTEM OF TIGARD SANITARY DISTRICT`
AT
THIS PERMIT MUST BE POSTED ON Tlt*DESCRIBED PREMISES tiNTIL COt4-
NECTION IS MADE AND INSPECTION OF CONNECTION HAS BEEN COM-
PL ETED.
PERMIT FEE PAID $.. . .........�.....I.-..........TIGARD SANIITTARY DISTRICT
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CONNECTION INSPECTED AND APPROVED
--- - -- Date Superintendc.,