1994, 03-16 Permit App: 94002332 Sewer�5Z13,73o$ 1_ q ,z -j3?-,
�IQiC� SEWER CONNECTION PERMIT APPLICATION FORM D3
DIq orc).�"4
THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
OB ADDRESS
11007 E 10th
(IF KNOWN)
PARCEL NUMBER:
ITY: Spokane, STATE: WA ZIP CODE:
WNER NAME: Steven L Wilson Lillian C. WilscAIDDRESS: s
ITY; STATE:
HONE NUMBER: sno a�a anu
ZIP CODE:
ROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION?
99206
YES
(CIRCLE E)
IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
ONTRACTOR: AI w , S A ,L/v, ADDRESS: .Dn �,]ti Irk L
'.ITY!,,pr MP. STATE: ZIP CODE: q,1.l'�4
'HONE NUMBER: q22.- 8Sn<p ,h
TATE CONTRACTORS LICENSE NUMBER: A LvJ Ql� A
TILITIES INSTALLERS PERMIT NUMBER:
NTERrOR PLUMBING ALTERATIONS? YES (CIRCLE ONE)
.NTERISR ALTERATION BY
.DDRESS:
:ITY :
STATE
PHONE NUMBER
ZIP CODE:
,ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION
............:# OF
BUILDINGS
X
50.00 =
50.00
INTERIOR PLUMBING
ALTERATIONS:# OF
BUILDINGS
X
35.00 =
TOTAL PERMIT
FEE
DUE $
50.00
i
1PPLICANT
SIGNATURE: �/� C`.T✓ DATE: -
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675