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rn.—+� .. _. .. . .... � . . <br />. . . � . . . � . , . <br />� Y <br />: <br />� � gS�: �� 3 � 8 Qgc� <br />, ;r- :,� _ �- ,�w� <br />��� �M p � .. �.i � <br />Sewer Applica�ion a��y���mit <br />(.c F ,/r�����y� <br />. - .Ofui��U:U'�:�� 33r-S <br />� � zs��a ,_ aW�z,.. �.s�� '''_" <br />, DATE _ <br />Service Address 5932 9rd Or t' Utiliry Account No. <br />' BillinpAddress 237 Elm St _ <br />City, Stete, Zip Hvrecc NA 98203 Permit Fee $ <br />. nwner salacc �mmee Connection Charge <br />� Conneclionby _ 'frunk S <br />Address Lateral S <br />CHART N0. <br />vncTING. � _G /4-4i .. <br />i <br />i <br />Phona <br />legel Deseription: _ <br />Lot 14 <br />Blodc <br />Plat <br />linmbcook Oiv 3 <br />� Unplatted Doscription: _ <br />Type ol Permit � Vainii <br />Remerks _ <br />IMPOIiTA1+Tl <br />CALL 1-800.424•5555 48•HOURS <br />PRIOR TO DIGGING <br />CALL 259•8810 FOR INSPECTION <br />Total Connection Charpe E <br />Utility Development Fee <br />70.00 <br />11.0U <br />Water g 179.00 <br />Sewer g <br />Tolal Developmonl Fee $ 179.0� <br />Sewer Bond Disinct �"I� <br />Abutling Lot Line <br />N, S, E, W tl. <br />Approved By <br />Issued By b <br />Customer Signatur . <br />Inspeclion By �� � ��- <br />Datelnspected $-13�`�3 <br />SEE SKETC�H ATTACHED <br />INSPECTION . � � 2 919 9 <br />