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M M <br />^l <br />Sewer Application aril Permit <br />a�F r Mk <br />DATE 2-14-04 <br />Service Address 417 `torRnn Rd <br />Billing Address <br />City, State, Zip <br />Owner Gene }Impel <br />Connection by <br />Address <br />Phone <br />Legal Description: <br />Lot <br />Block <br />Plat <br />Nalbach Constructinn <br />Unplatted Description: <br />Type of Permit <br />Remarks <br />niteTItior <br />IMPORTANTI <br />CALL 1-800-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8810 FOR INSPECTION <br />Utility Account No. <br />CHART NO <br />TO POSTING.-�12L <br />Permit Fee $ 30.00 <br />Connection Charge <br />Trunk $ <br />Lateral $ <br />Total Connection Charge $ <br />Utility Development Fee <br />Water $ <br />Sewer $ <br />Total Development Fee $ <br />Sewer Bond District <br />Abutting Lot Line <br />N, S, E, W _ <br />Approved By <br />Issued By <br />Customer Signature <br />Inspection By <br />Date Inspected <br />SEE SKETCH ATTACHED <br />INSPECTION29647 <br />ft. <br />