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PLICATION
(;I;FICE:726-3759
726-3769SPRINGFIELD OR 97477 INSPECTIOI LINE:
JOB LOCATION:.J
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CITY OF
ADDRESS:PHONE #:
CITY:STATE: Cr.rl(ZIP f;2YJA
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADM:.N. IIEB) = $16.20
CONTRACTOR:
ADDRESS:PHONE *:
CITY:STATEI ZIPz
CONSTRUCTION CONTRACTORS REGISTRATION #:iiXPIRES:
BY SIGNING THIS PBRMIT/APPLICATION , I AGIIBE T0 CALL FoR AN INS;'ECTI0N ONCE THE
SIBLE I.OR INSPECTION
PERMIT,, APPLICATION IS
BACKFLOII ON DBVICE HAS BEEN INSTALLED AND IS VI
(7 6e)ALSO
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FOR OIJFICE USE
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DATE OF APPLICATTON:
RECEIPT II: 6CIbI
e/o/rr 0: lt:?fo€27
?ISSUED BY:il*/al
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TOTAL AMOUNT COLLECTED t I [.ca