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pCt F-1 <br />Y H to <br />A <br />H tv <br />�H <br />to <br />z <br />8 r7 <br />C Hg <br />yzH <br />r qz <br />FA <br />8 rn <br />r <br />(� C7 CA <br />dm� <br />H O ;° <br />I <br />�MAW <br />I-Ijj <br />CHART NO. - <br />io <br />TO POSTW!. <br />sgsgW�sp s ss� <br />rmpSL hO� <br />F N* N M <br />Sewer Application and erm#_.s . <br />2 91 718 DATE "S125J93 <br />Service Address 12 81at ST SW <br />Billing Address Po aoi 1956 <br />City, State, Zip <br />Owner G 11 <br />Ari <br />Connection by �- 1 Jr r c "- <br />Address <br />Phone <br />Legal Description: <br />Lot _ 8 <br />Block <br />Plat cv eot5_on <br />Unplatted Description: — <br />Type of Permit <br />Remarks <br />New conuacticn <br />IMPURTANTI <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 />70.00 <br />Permit Fee $ _ <br />Connection Charge <br />Trunk <br />$ <br />Lateral <br />$ <br />Total Connection Charge <br />$ <br />n no <br />'Jillity Development Fee <br />179.60 <br />Water <br />$ <br />$ <br />471.00 <br />Sewer <br />Total Development Fee <br />$ <br />650.00 <br />Sewer Bond District <br />Abutting Lot Line <br />N,S,E,W — <br />Approved By <br />Issued By <br />Customer Signature <br />Inspection By��/ate <br />Date Inspected 7 -1Y <br />12 <br />INSPECTION <br />29121 <br />