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' ENGINEERING D'zl'�1R'i�ENT <br />BUILDING PEiifdlT INPOR�dATION <br />ADDk�SS � �7 �G> ,�/ <br />'` -Z���QG TYPE I�CI I�L�.-'� <br />1) AUILDING P�12MIT F !i � �� 1% �• ' <br />.fiE • �''r6 Z•• $ /�Q. �'t� <br />(A) PLAt� CIIECY, E'�E <br />S 4Z • a � <br />2) StiATER SERVICE TO B� PAID BEFORE BUILDJNG <br />PE:2h1IT IS ISSUED .�jq�� ///�� S ,f��.c:�?� <br />�r L ..c n __ <br />(A) TO BF. DETERb1INED BY PLBG. IT7SP. <br />/ f Ii�Ct1 �l'L�'� j(�, r, U <br />-- M'�t�/. � ¢ , o c' <br />i�) EXIST. WAT�R SERVICE� APPL. N0. '. <br />IC) APPROR. T,OCATION Q `� QC . � � � ��" . <br />d O�_ /�'/�-��Cc, CHART S-/ 1�Z <br />3) DRIVEh;AY P�RhiIT TO BE PAID DL•'POR� BUILDING <br />PER:•;IT IS ISSUED !�� FT. � _.��1 � . D/W (TYPE) ., $ � 2. S � <br />TOT,1I, * <br />9) SinTUS OF SEl•7F.R CHAI2GES: <br />F30\D_�� DISTR2CT � FOOTAG� %� <br />N� S� E, i•7. <br />SE�9EF CONSTRUCTION: <br />SEI9ER SERVICE: <br />SEY7ER COVNECTION CYJsRGES: <br />YEAR 7 �P TRUNK <br />/�co. /2 9/7 t� <br />LATEFAL <br />TOTAL CONN£CTZON CHARG� <br />SE14EP. PERI�fIT PEE <br />CATCH BaSIN P�R�:IT FEE <br />TO'PAL S�{+TER PERI9I'1' FEES <br />TRUNR <br />$ 5za'. s�-r� <br />S /�5, O L <br />$ 3/Z, �7 <br />Y• �V / O J�I <br />$ � Dp <br />$ <br />$ � • O c) <br />LATEPJsL $ 2, �� <br />$ /L/!� %G-�'E i-- <br />!1PPi�.^\. LOCATION OF SIDE SBWER OR Tc,E Itd THE P11�TN: �" <br />� S . �j/-'/�iL�iiK � <a C � G� n .y � � i / i i ..rs�ti�. �, .. l, .� _ <br />INFO LO):i�ILEll IIY: <br />RLVIEi� : <br />APPR�\'AL: <br />� <br />PRUJHCTS DTVLF;)0*; — <br />ENGIN?iL12I1JG U1;Y71RTPSF,NT <br />J_�' <br />na1•L <br />DATE <br />DA <br />� <br />