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' CHART N0. <br /> Sewer Application and Permit <br /> DATE �0 — �-� - 9 S <br /> Service Address —�-3 �y ��{ C�,v �T <br /> Utiliry Accaunt No. <br /> Billing qddress <br /> City, State,Zip __ <br /> Permit Fee a <br /> Owner <br />' Connecti�n Charge <br /> Connection by <br /> Trunk g <br /> Address <br /> Lateral a <br /> Total Connection Charge a <br /> Phone <br /> Utflity Development Fee <br /> Legal Description: <br /> Water y <br /> Lot <br /> Sewer � <br /> Block <br /> Total Development Fee a <br /> Plst <br /> Unplatted Descriptlon: ��A�cv �,/ y� ' / }? " <br /> Sewer Bond District <br /> lJc.a .�� � <br /> �k$—� �'`� ^"� " ' Abuttinp Lot Line <br /> ,a .-'�/_ "c ,�-_-�9.;.cR� �n P/L <br /> ------�*--� , N, 5, E,W � <br /> Type of Permit �;,� /�/ ' a[ � A �Q � pPproved By <br /> Remarks �S � �fL G , o/ Issued By <br /> 335 � ti <br /> V i`,,,� � , Customer Sfpnature <br /> IMPORTANT! <br /> CALL 1-800-424-5555 48-HOURS ' <br /> PRIOR TO DIGGING <br /> CALL 259-8810 FOR INSPECTION InspecNon By _ � / .f�! o� <br /> Date Inspected _ �� - /�,Lg,s <br /> SEE SKETCH ATTACHED <br /> CUSTOMER COPY <br />