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Sewer <br />a <br />2` O C� !- rJ <br />0' L7 wi i it M <br />H M M M <br />Application Ad Pexrn ppc� <br />nrJ-J HS lWW.]� F� .JC3�1�- <br />xc"e v& x, J L.- 3 fi <br />2 9 7 4 g DATE <br />Service Address ����� Z6) ' <br />; <br />Billing Address )/3 'zoN <br />City, State, Zip G <br />Owner <br />Connection by <br />Address <br />Phone <br />Legal Description: <br />Lot / M�. 3/-9G <br />l:l <br />Plat — <br />Unplatted Description: <br />Type of Permit `]1� l (� �(� U26 t&:2 t� <br />Remarks <br />IMPORTANTI <br />CALL 1-800-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8810 FOR INSPECTIUN <br />SEE SKETCH ATTACHED <br />Utility Account No. <br />CHART NO. <br />TO POSTING z- Z --4 <br />�l <br />i; <br />Permit Fee $ 7/3% <br />Connection Charge <br />Trunk $ <br />Lateral $ <br />Total Connection Charge $ <br />Utility Development Fee <br />Water $ 2 Z L7/, QiC <br />Sewer $ �X 9- 60 <br />Total Development Fee $ S a. OD <br />Sewer Bond District <br />Abutting Lot Line <br />N,S.E,W <br />Approved By <br />Issued By <br />Customer Signature <br />i <br />Inspection By <br />Date Inspected /O J"" _ <br />INSPECTION <br />?_9749 <br />ft. <br />