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�. <br /> . � .� '»^ �. .. ,.� :�:a!a�s�� . ,,. � <br /> ' � � � CHART NO. <br /> ia PG�TiN��-�- <br /> �: <br /> ra� <br /> a <br /> S= <br /> �Tr <br /> 4' <br /> pC� O "� C� G rt - <br /> `i: 17 [_. O �-J' b') �::. t� � lJ � <br /> L. � • � <br /> U7 .i� �. "` O " C� 1/i C .+ �.� <br /> f�l S O .i ... .P. ,..: �1 f� <br /> O C� [: <br /> (�I �.. ui M � N <br /> 7 .H ��q .i --1 .. .. . '' <br /> Sewer Application ar�d �erm�t µ �� 'j <br /> �[�1 � �._ , � � :� <br /> ' y � �4' c='� iu UO ifl3 � h y :_ G <br /> ' '° 23r83 � �� � � � r � �, � � � � � � � <br /> DATE y�//-';7�.� <br /> Service Address �%�f/%,- -�'�-'1' �:���(i i <br /> � _� Utd�ty A�cC�c urk'h'o. <br /> Bflling Address •'�/��//. i;��' l-h�^ � '_=� �li�' " — <br /> r � ICity, State,Zip �1 ri l�I E� 'L�i . �'��c%�,'7 Permit Fee $ J�� <br /> Owner � /��t Gz�:, :.: ,' �f,� ,;�-� I <br /> I Connection Charge <br /> Connection by�—�+�i!'O _ Trunk $ <br /> T' <br /> Address Lateral $ �' � <br /> / <br /> Total Connection Charge $ <br /> Phone Utility Development Fee ' <br /> Legal Descriptfon: Water $ ;�f 4� — <br /> Lot (''�Z <br /> Sewer , $ <br /> ��k Total Development Fee $ �j�/ �7� <br /> Plat _r��,�r'r ; . ��/�" <br /> Unplatted Description: Sewer Bond Dfstrict <br /> Abuttfng Lot Line <br /> N, S, E,W g, <br /> Type of Permft >'%r'E b'--�=-''�'Yl� '►e Approved By ' <br /> Remarks Issued By • '—' <br /> Customer Signature— <br /> IMPORTANT! i <br /> CALL 1-800-424-5555 48-HOURS <br /> PRIOR TO DIGGING <br /> CALL 259-8810 FOR INSPECTION �nspection By_l '� G'��lr�tan <br /> Date Inspected _ �'�-5y <br /> , <br /> 3EE SKETCH ATTACHED <br /> INSPECTION ' ��. 2 �� ,�j Z <br /> - --------- - - - ------- ----- J <br />