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� <br />0 <br />Sewer Application and Permit <br />DATE `5 - _,} - 9. r <br />Scrvice Address ��_G� .� H;,� �� Utility Account No. <br />Billing Address <br />City, State, Z;o Permit Fee $ <br />Owner <br />Connection by _ <br />Address _ <br />Phone _ <br />, Legal Description: <br />Lot <br />Blodc <br />Plat <br />UnplattedDescription: �,!(�� c�AI � ht/-J <br />���L � 7 ' S. o! /1�— <br />��� ii , i `- <br />Type of Pertnit ��_ _ �/� c���� <br />Remarks _ <br />IMPORTANT! <br />Conne�:tion Charge <br />Trunk <br />Lateral <br />Total Connection Charge <br />Utility Development �ee <br />Water <br />Sewer <br />Total Developmen; FAe <br />Sewer Bo�d District <br />Abutting Lot Line <br />N, S, E, W _ <br />Approved By _ <br />Issued By <br />Customer Slpnature <br />$ <br />$ <br />$ <br />$ <br />$ <br />:� <br />CALL 1-800-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8810 FOR INSPECTION Inspection By „d'L `�/ -� <br />Date Inspected �' �� 7'.`'S^ <br />SEE SKETCN ATTACHED -- - • � , - � � <br />CUSTOMER COPY ., , " . . . � _ .. ._ ..._ .: <br />h. <br />