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CHART NO. <br /> � <br /> Sewer Appiication and Permit <br /> DATE �n - s- 9s <br /> ServiceAddress ��r' � �M �� UtiliryAccountNo. <br /> Billing Address <br /> Ciry, State,Zip Permit Fee $ <br /> Owner Connection Charge <br /> Connectiqn by Trunk � <br /> Address Lateral $ <br /> Total Connection Charge $ -- <br /> Phone Utility Deveiopment Fee <br /> Legai Description: Water $ — <br /> Lot Sewer $ <br /> Block Total Development Fee $ — <br /> Plat <br /> Unptatted Description: ��c o cf S : d Q Sewer Bond District <br /> C Qy�a .r eM a�i.✓ -- Abutting LotLine <br /> � �� C O ne ��/ — , N�S, E��' ft. <br /> Type of Permit ��• -� p�.-- ApP�oved By <br /> Remarks C � � P/____� 3 � �ssued By <br /> � � p� � Customer Signature <br /> IMPORTANT! <br /> CALL 1-800-424-5555 48-hiOURS <br /> PRIOR TO DIGGING <br /> Inspection By '� �" � <br /> CALL 259-8810 FOR INSPECTION � 0 �., 9 � <br /> Date Inspected <br /> SEE SKETCH ATTACHED <br /> CUSTOMER COPY <br />