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0 <br />----. ; <br />-- .-,---,-,,----�-,-- -- .. <br />.'ICHART NO. . <br />' Sewer Application and Permit <br />� �n��!� DATE `. . <br />- �...; . jl - 1�-; <br />Service Address �= G G./ . , �r !. �•i l! Utility Account No. <br />Billing Address `• 1/'� � � i <br />City, Siate, Zip '�I �' ��%� Permit Fee $ <br />Owner ' ' ' � � .! : r 1.� � Connection Charge <br />Cannection by _ <br />Address <br />Phone <br />Legal Description: <br />Lot <br />Blo�k <br />Plat <br />Unplatted Description: <br />TO POSTIHG {-�5-5-I <br />' } Trunk <br />Lateral <br />Total Connection Charge <br />Utility Devetopment Fee <br />Water <br />Sewer <br />Total Development Fee <br />Sewer Bond District <br />Abutting Lot Line <br />N, S, E, W _ <br />Type of Permit ��' .� Approved Dy _ <br />Remarks .���G'ca/ ewf�„ ,�/ � G�, � Issued By <br />" n �YC �"� �o",� �" � S �,—e CustomerSignature <br />IMPORTANTI <br />CALL 1-500-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259•8810 FOR INSPECTION <br />SEE SKETCH ATTACHED <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />Inspection By _ �G bP�nz�� <br />Date Inspected — �� L sy <br />INSPECTION <br />2?7C9 <br />ft. <br />