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Sewer App <br />a� <br />(e <br />i <br />�Q <br />M J <br />lication and Permit <br />29699 DATE <br />Service Address <br />Billing Address a -- <br />Clty, State, Zip z5ly 77, `ID �d✓/ <br />Owner <br />Connection by Ar W-m / Jam____ <br />Address <br />Phone <br />Legal Description: <br />Lot <br />Block <br />Plat <br />Unplatted Description: <br />Type of Permit 192, <br />)11 <br />Remarks <br />IMPORTANTI <br />CALL 1-800-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8810 FOR INSPECTION <br />Utility Account No. <br />;HART NO. — <br />TO POSTING_ <br />Permit Fee $�. -� l <br />Connection Charge <br />Trunk $ <br />Lateral $ <br />Total Connecticn Cnarge $ <br />Utility Development Fee <br />Water $ <br />Sewer $ <br />Total Development Fee $ <br />Sewer Bond District <br />Abutting Lot Line <br />N, S, E, W _ <br />Approved By <br />Issueo By _ <br />Customer Signature <br />Inspection By <br />Date Inspected _ 3 y' 7 — <br />SEE SKETCH ATTACHED <br />INSPECTION ? C 6 9 l <br />ft. <br />