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Sewer Applicati <br />2:;553 <br />� <br />- - - ., �, <br />� ,,. :-, - .; �, <br />- � .- , -� :+ <br />r. � ,, � <br />on and�P�rrr�i�,�: �,, <br />� z <br />. � r.�� �� j r�,i r� ri -z,i u5 <br />`�-' 2�1515'4z �r., ... �. :_ o. <br />DATE <br />Service Address 815 N Broadwaq (Smito 7 h 8� Utiliry Account No. <br />Billing Address 1429 Sroadvay <br />City, State, Zip Evaretc 98201 <br />SRCR A�soc <br />Owne� — el h EntezPrieee <br />Connection by a <br />Address <br />Phone _ <br />Legal Description: <br />Lot <br />Block <br />Plat <br />Unplatted Description: <br />Typeof Permit Cap-Off <br />Remarks <br />IMPORTANTI <br />CALl.1-B00-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8810 FOR INSPECTION <br />SEE SKETCH ATT'ACHED <br />CHART NO. <br />TO POSTING !��-�� <br />� � 1 r'� �1 <br />•i o o cz [- <br />� �� A p N <br />� �� � <br />����'���� <br />:���SrT,_-' ,,g � <br />Permit Fee $ <br />Connection Charge <br />Trunk <br />Lateral <br />Total Connection Charge <br />Utility Development Fee <br />Water <br />Sewer <br />Total Development Fee <br />Sewer Bond District <br />Abutting Lot Line <br />N, S, E, W <br />Approved By <br />Issued By <br />$ <br />$ <br />a <br />l0.00 <br />Customer Sfgnature <br />/�S/JQv�Q~ <br />V�° � �� 2� <br />Inspection By _ <br />Date Inspected <br />INSPECTION <br />"� 2go53 <br />n. <br />