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Sewer Applicat <br />29717 <br />CHART NO. <br />0 <br />op op p p <br />r $ t7 S S� g O tl g 4j <br />0 6I :% ruPi th P G <br />ion4 d Per it � <br />IR <br />DATE < -3-4 <br />n <br />r <br />Service Address 12 2?' 7 1•t L I - <br />Billing Address ' q5tP Ar -SL <br />City, State, Zip — , J 1 '/ 9 yG 2 <br />Owner /I iL %lfnn ,I r iSf . <br />Connection by <br />Address <br />Phone <br />Legal Description: <br />Lot <br />Block <br />Plat <br />Unplatted Description: <br />Utility Account No. <br />TO POSTINGG.G - G � <br />Permit Fee $ _ 7/)• 0/) <br />Connection Charge <br />Trunk $ <br />Lateral $ <br />Total Connection Charge $ <br />Utility Development Fee <br />Water <br />Sewer <br />Tots' Development Fee <br />Sewer Bond District <br />Abutting Lot Line <br />N, S, E, W <br />Type of Permit `Z l6IA I e- C1) I)C'rfi L f t , _ Approved By <br />Remarks Issued By _ <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 />Customer Signature <br />$ _ l79 c6 <br />$/l7/•GD <br />$ ! ` `JCi • (/l <br />Inspection By ` <br />Date Inspected <br />INSPECTION <br />29732 <br />ft. <br />