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W <br />-` <br />CRY of cv Irett = S 8 <br />Sewer ArPplication and Permit <br />NO. 282I0 DATE <br />Service Address __7mod_ t _ <br />Billing Address <br />City, State, Zip rw r tt'____ __gn2n_ <br />Owner <br />Connection by <br />Address —15617 Wastutck a� <br />li <br />Phone <br />Legal Description: <br />Lot <br />Block <br />Plat <br />Unplatted Description <br />Type of Permit <br />Remarks <br />IMPORTANTI <br />CALL 1-800-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8810 FOR INSPECTION <br />SEE SKETCH ATTACHED <br />Utility Account No. <br />CHARM NO. <br />TO POSTING —.�o- <br />Permit Fee $ 10 no <br />Connection Charge <br />Trunk <br />$ <br />Lateral <br />$ <br />Total Connection Charge <br />$ _ <br />Utility Development Fee <br />Water <br />$ <br />Sewer <br />$ <br />Total Development Fee <br />$ _ <br />Sewer Bond District <br />Abutting Lot Line <br />N. S, E, W R <br />Approved By <br />Issued By. .T On.-k. 11 <br />Customer Signature <br />Inspection By I _ <br />Date Inspected <br />ItT 1P:`.GIION <br />No. 28210 <br />