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G; <br /> CHART NO. —.--- <br /> � � � Tfl PfICTI Nfy �j��,� <br /> Ox1x �� ... , . . . _ . <br /> Ca Iti <br /> Cyy <br /> y �H 5ew�r Application and Permit -; : �; � :_ <br /> , <br /> K' O � . .. l � � C� t+1 <br /> H #f - . - � .,. . _ '. . <br /> Ox0 <br /> � y N 7'! S �i� DATE 4-�-`-'' <br /> o ry-i � I Service Address S"`= 1 ;t nr �; Utiliry Account No. <br /> H [�+7 g � zs� Hl,n sc � <br /> o� ao Billing Aduress <br /> �H z City, State,Zip f�verett taA 93''U:! Permit F��. $ _ ���'��' . �. <br /> g � y Owner Selecc Hoc��r, _ Connection Charge <br /> H <br /> ��� y Connection by �'`"" `• ~�� Trunk $ <br /> � r <br /> y o y Address Lateral � <br /> Total Connection Charge $ <br /> � Phone ZS$-1503 Utility Development Fee <br /> Legal Description: <br /> Water $ ���'`�� <br /> I �� ��� 30 of Flannbrnnk Mv 3 Sewer $— <br /> l79.00 <br /> Block Total Development Fee $ <br /> i '_`�j Plat <br /> ��� ut.in <br /> , Unplatted Description: Sewer Bond District � <br /> Abutting Lot Line <br /> I ��I�I N,S� E,W ft. <br /> Type of Permit '"'u '-�'nO1cc ion Approved By <br /> �1� ,,:i <br /> � Ramarks Issued By , , . , _� <br /> Customer Signature – <br /> I _ <br /> L� IMPORTANT! <br /> CALL 1-B00-424-5555 48-HOURS <br /> PRIOR TO DIGGING /� <br /> Inspection By ( 5 /"� <br /> CALL 259-8810 FOR INSPECTION � ,� _, <br /> , Date Inspected � <br /> SEE SKETCH ATTACHEQ ., ;. � � � <br /> INSP�CTION <br />