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lVCrCtt <br />e <br />IQ <br />C@y of Etnnu 8 <br />Sewer Application and P6r. it <br />NO.28495 DATE _gap";., tool <br />Service Address — II- ieirriar :re <br />BilligAddress 2e20 661h st se <br />City, State, Zip — i� <br />Owner Crary Yanked <br />Connection by <br />Address <br />Phone <br />Legal Description: <br />Lot +. <br />Block — <br />Plat yafr..., fit. nt. /2 <br />Unplatted Description: <br />Utility Account No. <br />Permit Fee $ <br />Connection Charge <br />Trunk <br />;.HART NO. <br />TO P0ST1WN!d <br />Lateral <br />Total Connection Charge <br />Utility Development Fee <br />Water <br />Sewer <br />Total Development Fee <br />S <br />a <br />$ <br />$ 224.00 <br />$ 549..e— <br />$ 813.00 <br />Sewer Bond Distdct 1--(1 bled) <br />Abutting Lot Une <br />N. S, E. W _ <br />Type of Permit vey Cotyrotlnc Approved By p <br />Remarks Issued By— <br />Customer Signature <br />IMPORTANTI <br />CALL 1-900-424-5555 49-HOURS <br />PRIOR TO DIGGING <br />CALL 259.9910 FOR INSPECTION Inspection By <br />Date Inspected <br />SEE SKETCH ATTACHED No. 28425 <br />INSPECTION <br />R <br />