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� . , ., �� <br /> CHART NO. j <br /> '�` I <br /> �Mi,� -. <br /> �Yk ' L, ; ,-: Tf1 PncTiqf ��I Z--�r� i <br /> k ', 'y' I <br /> Sewer Application and`:�P�rrreit <br /> ,� � ,-, �, :� <br /> - - �� = � <br /> - �; _; �_� ; <br /> . �::� =:� _. .. � <br /> ? S 7 31 DATE ��Is-�-9a I <br /> Service Address 1U020 F.verBreen k�� Utility ACcaunt No. <br /> Billing Address 1300 Sw 6th Ave <br /> City, State,Zip P�rtlund OR 97201 permit Fee $ 10.00 <br /> Owner _ Mocel 6 Inc Connection Charge <br /> Connection by Trunk $ <br /> Addres� Lateral $ <br /> Total Connection Charge $ <br /> Phone Util(ty Development Fee <br /> Legal Description: Water $ <br /> Lot Sewer $ <br /> Block Total Developm�int Fee $ <br /> Plat _ -- <br /> Unplatted Description: — Sewer Bond District <br /> Abutting Lot Line i <br /> N�g� E�yy ft. I <br /> Type of Permit �an °ft Approved By <br /> Remarks Iss�sd 3y r� ! <br /> � <br /> I <br /> _ Customer Signature <br /> IMPORTANT! <br /> CALL 1-800-424-5555 48-HOURS � <br /> PRIOR TO DIGGlNG <br /> CALL 259-8810 FOR INSPECTION Inspection B� � �- � � <br /> Date Inspected 6 0 � � I <br /> i <br /> SEE SKETCH ATTACHED � <br /> INSPECTION � = ��7� � I <br /> I_ i <br /> � � <br />