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�• <br /> CHART NO. — ' <br /> F��� <br /> .— <br /> 4"��"� <br /> r x�' ' T(l P(15TIN('� _S-��� 3 <br /> �� �� <br /> .; H <br /> �.�; �7 <br /> y �� �; S�wer Appiicat�on and Pei�mit <br /> n o C� I <br /> pNe � , .R .,, ._ DATE =�/�/j=t — <br /> � �g i <br /> �� � 1C„��'_ 7ct: :..�c t: UtilityAccountNo. — <br /> zH� <br /> ' Service Address <br /> ty- y z 5.',�;,� . <br /> H y Billing Address � , ,;i; <br /> C7 �H � Cvere[t NA 532Q3 PermitFee $ <br /> � Cy� Ciry,S;ate, Zip <br /> � �r � Owner _ tieintz xaymona Connection Charge � <br /> [� <br /> $ •�,�o.00 <br /> '� ��' Connection by nction Gackhoc Trunk <br /> Address 3^�' "' �' Lateral $ �3c1 �� <br /> tiverett W; 982L�� Total Connection Charge $ <br /> i <br /> Phone 15z'"�i i�+ Utility Development Fee <br /> '..., „� � Legal Description: Waler � <br /> 47LOQ <br /> �! �j Lot Sewer $ <br /> ' Total Qevelopment FEe $ %+71.CO <br /> ti> Block <br /> �.,. ' <br /> �� 'i Plat ;;ond -.i1 . <br /> Unpla[teo Description: Sewer Bc�d District <br /> ' "� Abutting Lot Line <br /> II <br /> N� S, E,W ft. <br /> '°' �;e�r peL:�:it Approved By <br /> Type of Permit �.;, <br /> ' Remarks Issued By <br /> _ � i <br /> Customer Signature <br /> . <br /> t�� IMPORTAN7! <br /> , I <br /> �� CALL 1-B00-424-5555 48-HOURS <br /> � PRIOR TO DIGGIMG �� ��� <br /> ' Inspection By �_ o <br /> CALL 259-8810 FOR INSPECTION Date Inspected S /� /� � <br /> ' SEE SKETCH ATTACHED .; ;y � �� ! <br /> INSPECTION <br />