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1 rQ <br />C:1 <br />�ca <br />evere t <br />e <br />r•� �t E��ii � a e+ w <br />Sewer Application and Per l itS <br />f: tf. 1 rJ <br />No. 28543 DATE <br />Service Address <br />Billing Address <br />City, State, Zip _ L�••� n• <br />Owner — ueeC�l <br />Connection by <br />Address <br />Plane 4k5 we — <br />Legal Description.: <br />Lot <br />Block 015 <br />Plat _ ' '--` — <br />Unplatted Description: _ <br />Type of Permit Cev off <br />Remarks <br />I� <br />.1 U <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 />CHART NO. <br />TO POSTING t <br />Permit Fee $ _ 2-50 — <br />Connection Charge <br />Trunk $ <br />Lateral $ <br />Total Connection Charge $ <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 tt' <br />Approved By <br />Issued By <br />Customer Signature <br />Inspection By <br />Date Inspected <br />INSPECTION <br />No. 28543 <br />