1993, 05-17 Permit App: 93003605 Sewer '6CI5 ` ' �3 X05
�s�l�t 5 .-
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLEDOUTACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
T tt ( IF KNOWN)
' o` PARCEL NUMBER:
JOB ADDRESS: / 7�.��
STATE= _G ZIP CODE= /
CITY=
OWNER NAME: =�' i 4°'� ADDRESS: if .r :411.
STATE 'HONE=
CITY=
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 0
(CIRCLE
*IF PROPERTY OWNER INSTALLING SEWER , HMUST FIERST CONTACT
ISSHEDUTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS
A( WAYS AGT1VE _ ADDRESS
CONTRACTOR= 2A? qac-8
rT g1.2 PHONE:
CITY: j,bKI�hIF �A _
STATE CONTRACTORS LICENSE NUMBER . . : 141.-WA 1,at .0(o P J
UTILITIES INSTALLERS PERMIT NUMBER=
INTERIOR PLUMBING ALTERATION .
YES NO (CIRCLE ON5X/
INTERIOR ALTERATION WO- BY . . :
PHO '
ADDRESS
STATE= IP CODE=
CITY:
*ONE PERMIT REQUIRED FOR EACHSEPARATEBUILDING , SHOP , GARAGE, ETC
THAT WILL BE CONNECTED TO THESEWER .
SEWER CONNECTION
# OF BUILDINGS _ X 50 .00 = ______ __
=
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 �O
TOTAL PERMIT FEE DUE
i
APPLICANT //�
SIGNATURE -
41
'OKANE COUNTY DEPARTMENT WOFA 99BUILDINGS
260 )456-3675
WEST 1026 BROADWAY AVENUE SPOKA