1999, 10-18 Permit App: 99010039 SewerSpokane County Division of Utilities
/661 CONNECTION PERMIT
3 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.
Also note that sewer permits are valid for 12 months from the date of issuance. No extensions will be granted.
PROJECT INFORMATION
Job address:
Dry Line
Sewer? (YIN)
Owner's name:
Clty: t
__)1, 6 C
Zip:x
1( -70";(: -
Parcel
] 7j(:(:Parcel number(ifknown):
City/State:
Zip:
Phone:
First-time contractors or home -owners performing the installation must first contact the utiliti s department (ip person or via phone
[456-3604]) before a permit can be issued.
Name of Utilities Division person contacted:
CONTRACTOR INFORMATION
Contractor (company name):
State contractor license number:
/v4
Business address:
City/State:
Zip: Phone:
Contact Name:
Phone:
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle one
Fill out the in ormation in the table below i a , licable**
Contractor (if different from above):
Business Address:
Phone:
City/State/Zip:
For pluns}iing reversal jee rn�
riiir,t ivn, eereverse
e.Ql"E
FEE INFORMATION
Sewer Connection: Number of Buildings X(times) $lOO (per bldg) = $
TOTAL FEE
• For a single-family residential unit, one permit is required;
• For a condominium, townhouse, duplex, triplex or fourplex with separate ownership (as determined by lot lines) separate
address and separate stub, one permit is required per address per stub;
• For a single building duplex, triplex or fourplex with single ownership, one permit is required
• Multiple buildings (apartments, industrial complexes) with single ownership, one permit required per building connecting to
the sewer.
(For situations not covered here, call the County Division of Utilities @ 456-3604)
APPLICANT SIGNATURE:
Date:
Return to:
Spokane County Division of Building & Planning
West 1026 Broadaty Avenue * Spokane, Washington 99260
PHONE: (509) 456-3675 * FAX: (509) 324-3198 * TDD: (509) 324-3166
Spokane County does not dtsc mmate on the bans of disabthty m the *Mass= to, or treatment or employment In, its programs or [[.mines. to/u/M ehe.e.e\sewer mk