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� <br /> � <br /> '���, <br /> i . _. r _ . <br /> CHART N0. _- _ -____-. <br /> ��� TO PO,TI�dG ��_,, ��. <br /> I� ' ���� �; � A : ;a �' — — <br /> I : � , - � �_ <br /> 'i ��wer Application an,d �erm�t <br /> - , <br /> .., _ � _ � _ _ _ <br /> , � �$^9 4 DATE . �12/22/i2`. <br /> i <br /> i 731 40th P1 <br /> Service Address Utilily Account No. <br /> III Billing Address 3240 Gnel�ke Ava 1! 6200 <br /> I Ciry,State.Zip se.eele u� eato2 PermitFee $ 7��.��� _ <br /> II Owner Uellq Anr�ai Iac Conneclion Charge <br /> ', Connection by Se v�'`� E+' �a� Trunk 5 — <br /> IAddress Lateral $ <br /> I, Total Connection Charge g 0.00 - _ <br /> I Phone Utility Davelopment Fee � <br /> Legal Dzccription: Water $ 224.00 � <br /> ILoi 31 Sewer $ 5�9,00 <br /> ' Block — - TotalDavelopmentFea $ D13.Cn <br /> iPla� 611verba�Y, <br /> Unplatted Descnplion: Sewer Bond District _ <br /> Abutting Loi Line <br /> IN,S,E,W Ic I <br /> Type ot Permit Nev comnccion _ Apprcved By — � <br /> � Remarks Issued By GR � <br /> _ -. - ' <br /> � CustomerSignaWre— � <br /> IIMPORTANTI <br /> I <br /> CALL 1-800-424-5555 48-HOURS <br /> PRIOR TO DIGGING <br /> Inspedion By C"/'���� <br /> CALL 259-8810 FOR INSPECTION <br /> Date Inspected _�' 'j <br /> SEE SKETCH ATTACHED <br /> IINSPECTION _ � _ ��� � <br /> �� <br />