2007, 04-09 Permit App: 07001920 SewerSpokane County Division of Utilities
SEWER CONNECTION PERMIT APPLICATION FORM
PLEASE NOTE: This application form must be filled out accurately and in its entirety. and signed, or a permit will not be issued. Sewer permits are valid for 12
months form the date of issuance. A separate right-of-way permit is required for any work performed in or from the public right-of-way. r111 interior
plumbing and electrical work requires separate permits.
PROJECT INFORMATION
9 --o
Job Address: ///, . Ac P/rgbr L,r,
Parcel Number: *ES / -57 a / / e Lot: 7 _ Block:
Project Name:
MID Name -
CHECK APPLICABLE BOXES
,21' Regular
❑ Dry Sewer
❑ Repair
❑ Addition
O Abandonment
Residential New
O Commercial 0 New
O Temporary
Owner's name. -ria-J-3 ;pr t• t
Address 'et) R it 7 2-
City/State: 5.,,�//i
Zip: SSo/G
.n -
Phone: Sc.,e - - 11-/S 1
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED.
SIGNATURE OF UT11.ITIES DIVISION PERSON CONTACIT.D:
Cometor (company name):
Sate contractor license number.
Ain e i *in a el / Yr-,
Business address:Rj, re-,/ ) z
City/State: GL_
•CC- 4-1-.-7
Zip: 55 orp
Contact Name'
otrrJ
Phone Number 5 e1 3 -- S '7 7 a
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle one
Fill out the information in for table below if appBrable1
0 County 0 City of Spokane Valley
Contractor (if different from above): Phone:
Business Address: City/State/Zip
- . **For Spokeme Gun* pbnnbin,( rrversa/fee information, see merle sick JrbllJdrjll.^�- �;
- FEE INFORMATION
Number of Buildings connecting to sewer / X (times) 5100 (per bldg) = 5 /Om •-+ $70.00 = / / O • -
• For a single -randy residential unit, one permits required,
• For a condominium, townhouse, duplex, triplex or fourplrx with separate ownership (as deremuned by lot lines) separate address and separate stub, one permit is required pet address per stub;
• For a single budding duplex, triples or fourpkx with single ownership, one permit is required
• Multiple buddings (apartments, mdusnial complexes) with single ownership, one permit required per budding connecting to the sewer.
(FOR SITUATIONS NOT COVERED HERE, CALL THE COUNTY DIVISION OF UTILITIES AT 477-3604)
Is any of the work to be performed in or from the public right-of-way? 0 Yes O No
❑ C 0 City of Spokane Valley
SPOKANECOUN Y
RIGHT OF WAY PERMIT
APPLICANT SIGNATU
Owner or Contractor (circle on
DATE: 42. - S -
'Method of Pay nt:
❑ Cash Check 0 Visa 0 MasterCard 0 Discover Card
Expires:
Date:
Bankcard Number:
Authorized Signature:
Spokane Comm: Department of Building and Planning
1026 West Broadway :1. enue'Spokane WA 99260
'1'd No. (509) 477-3675 • Fa% No. (509) 477-7198' 'IDD No. (5119) 477-7133
UTILrfES DIVISION
N. Bruce Rawls, P.E., Utilities Director
A DIVISION OF THE PUBLIC WORKS DEPARTMENT
SPECIAL CONNECTION CHARGE (SCC)
PAYMENT OPTION SELECTION RECORD
PLEASE NOTE: Form must be filled out accurately and in its entirety, and signed, or a permit will not be issued.
DATE: 4 ) 7
SITE ADDRESS: KI • i 1 I 2 e,L.L (20) PARCEL#: 45151 • 1105
OWNER NAME: , 4 o CA-Viart, c s�
OWNER ADDRESS: -I& PID ;3� x 7 2_ � .�� %JJ ,
Payment Option Selected (Check One):
1
1. ( ) SCC and General Facilities Charge (GFC) ( 5475. --)paid at issuance of Sewer Connection Permit.
Total of SCC & GFC
Received by:
Amount Paid: Receipt#: Check#:
CC and GFC 95/47D.- ) to be paid at closing of sale of the property.
Total of SCC & GFC
( ) SCC ( ) paid at issuance of permit. The GFC
monthly payments, with no interest, upon establishment of Sewer Billing Account.
Received by: Amount Paid: Receipt#: Check#:
to be paid in 24 equal
4. ( ) SCC and GFC ( ), to be paid at
Total of SCC & GFC
period upon establishment of Sewer Billing Account.
per month (includes interest) over a 20 -year
5. ( ) Other:
I understand that the above figures are based on the.current use of the property and that if the use of
the property chgesiryif uture additional Sewer Connection Fees may be required.
�— ,
Signature of Property Owner or Property
Signature Utititites Staff
ner's Agent Date
3q.cy UR4JAusc,-u
SCC Payment Option Form Revised 09/08/05
4, o7
Date
1026 W. Broadway • Spokane, WA 99260-0430
(509) 477-3604 • FAX: (509) 477-4715 • TDD: (509) 477-7133
INSPECTOR: ILL /G/ SPOKANE COUNTY UTILIT
a � � Ob PIPE FLOW TYPE &SIZ
FINAL
FI L INSPECT. DATE:
INSPECT. DATE(S): Z'l706 PROJECT N
ADDRESS: N • 1106 3LAILE 1Z0/NJ,
SEWER DISTRICT/SUB-DIV.: \V77iktETZ ("xi0D pew (it7.
SIDE SEWER INSPECTI N REPORT ACCT. No. y/'i' THfL� /t/
RAVITY ❑PRESSURE ❑ BOTH PVC 0-3034 0 6" PVC 0-3034 ❑ ER:
0.: d5 877'o OWNER:
CONTRACTOR: siCGLEZ L. LJXG
PARCEL No.: 4S) . IIUS LOT: IRK:
STRUCTURE TYPE: (51IEW ❑EXISTING ❑ADDITION
iNGLE FAMILY RESIDENTIAL
DUPLEX 0 TRIPLEX 0 FOURPLEX 0 ZERO LOT LINE
❑ BUSINESS / COMMERCIAL 0 MANUFACTURED HOME PARK
❑ APARTMENT/CONDO # UNITS ❑ TEMPORARY
EASEMENT AGREEMENT REQUIRED? OYES ❑RECORDED
TYPE OF INSPECTION
EGULAR CONNECTION []EXTERIOR DRY SEWER CONNECTION
SEWER STUB [INTERIOR DRY SEWER CONVERSION
❑MAINUNE TAP ❑MAINLINE (PRIVATE) El CUT -IN
DORY SEWER [CORE MANHOLE
❑REPAIR ❑STUB ABANDONMENT
❑FOLLOW-UP ❑ADD-ON ❑OTHER (SEE COMMENTS)
WAIVER OF REGULATIONS REQUIRED? ❑YES ❑RECORDED ['SUBSTANDARD PIPE CONNECTION DOTHER (SEE COMMENTS)
DEFICIENCY: 0 YES ❑ CONSTRUCTION
0 ADMINISTRATIVE (SEE COMMENTS)
COMMENTS: ,v07E. 6" C4744j 1-1406 } _
TANK( S) ABANDONMENT INSPECTION: OYES ONO */
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INTERIOR PLUMBING
❑YES El NO /A
PROJECT No
BY:
BILLING INFORMA ION
Er PENDING anOlVE
BILLING/_O 6
MATE: •
- — — - EXIST. SEWER LINE
O SHUT OFF VALVE
® DRYWELL
BACKWATER VALVE/BWV
SS SEWER STUB
0 CONNECTION POINT
E.O.P. EDGE OF PAVEMENT
G/M GAS METER
DE ELECTRICAL
W M WATER METER
o
CLEANOUT
POWER POLE
O' MANHOLE •,
STORM DRAIN
CI HYDRANT
i CENTERLINE
B.L. BUILDING" LINE
-- —>-—- — —
DASHED UNE 1101H ARROWS INDICATES
90RED SEC11014 OF SEVER UNE
S/w SIDEWALK
C = DEPTH
C.I. CAST IRON
0.B. ORANGEBURG •
= FITTING
H.D. HEALTH DISTRICT
END FOUNDATION ////
❑ COPY TO B & CE
❑ COPY TO HEALTH DIST.
❑ OTHERS:
NORTH ARROW
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