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_-----__ --�-- <br /> _ .-� _ _ <br /> -- ------ <br /> ��-_. . <br /> CHART NO. — <br /> � <br /> y �H � TO POSTING_s�— <br /> � n� I,i � <br /> c � H � <br /> � � H '�� Sewer Application and Permit <br /> Ky � � <br /> � H '�mJ I, � �) ^ �� ':� J/"l0�:., � <br /> cnH . . . <br /> DATE ` " <br /> �y x � ' 152o ttoye <br /> y l7 Service Address Ulility Account No. <br /> � � � Billing Address �� <br /> G�o C] ' 30.0� . <br /> z y � � City, State,Zip L'verett kn 96201 Permit Fee $ <br /> � �+ y Owner r.le courcnev — Connec[ion Charge <br /> $ <br /> g tl ai I Connection by � � ���'�---�-- Trunk $ <br /> �� � � Address — Lateral ' <br /> y o y Total Connection Charge $ <br /> Phone .— Ulility Developmenl Fee <br /> , Legal Desc��ption: <br /> Water $ ' <br /> ��'� Lo� — Sewer $ <br /> �� Total Development Fee $ <br /> Block — <br /> f�� I Plat <br /> I �.,,,� Sewer Bond District <br /> Unplatted Description: _ <br /> � Abutting Lot Line <br /> �1r_` II - �`1� S,E�W n� <br /> I �it�:ncicn/F.enais Approved By <br /> Type of Permit L <br /> ��1�� � Remarks Issued By r <br /> � <br /> I Cuslomer SignaWre <br /> ----- '� <br /> �� �' IMPORTANT! <br /> �� i <br /> CALL 1-800-424-5555 48-HOURS <br /> PRIOR TO DIGGING <br /> Inspection By _ G'/�'���`"� <br /> CALL 259-8810 FUR INSPECTION Date Inspected i-1 Z "' � <br /> SEE SKETCH ATTACHED <br /> INSPECTION <br /> ------ � <br />