1995, 03-27 Permit App: 95001800 Sewer 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. 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 Owner's name:
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City: S &.4-tio. City/State: 45, 1/323 , 'JP c Z-
Zip: Zip: a/9 7-7-3
Parcel number (if known): Phone:
X (Yr Qi 8i.1‹ z ORAVc.eG1:$r Pc-k 407— �► ?7 i /43q3---7',7
First-time contractors or home-owners performing the installation must first contact the utilities department (in
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:
Business address: Utilities installers permit number:
City/State:
Zip:, Phone:
INTERIOR PLUMBING ALTERATIONS (if applicable)**
Contractor (if different from above): Phone:
Business Address: City/State/Zip:
** For plumbing reversal fee information, see reverse side of this form.
FEE INFORMATION
Sewer Connection: Number of Buildings X (times) $50 (per bldg) _ $
TOTAL FEE
* One permit required for each separate building, shop,garage, etc., that will be connected to the sewer.
* Condos, townhouses, &2-3-and 4-plexes require 1 permit per address/stub.
*Multiple buildings (apartments, industrial complexes) require 1 permit per building.
(For situations not covered here, call the County Utilities Division @ 456-3604)
APPLICANT SIGNATURE: Date: -1-,2/
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Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675