Loading...
HomeMy WebLinkAboutPermit Backflow Test 1999-1-25 . siNe FIELD . , . e~youto _..~,' 'BeQon laW reQulr ~ Utility BACKFLOll PRSViRNTIOff fBID@f.B~~%'MO:i ' iollc.OIar.ve\!lP W.~lElID1S a~ 952-001' , NYM~52_0~~' ~O tRiijl~Ahe rules by . ' . OAR 9 . cOpies 0 e 225 FIFTH STREET ' In You may obtain te' the telephon OFFICE: 726-3759 SPRINGFIE::.D OR 97477 009~illng the center. (N~ Utility NIINSlil!eFIC: 1 LINE: 726 _. 3769 -------:----------;--------------n%in"b". 10. :;O~~60:;:l,,<,'2'':' ').-------.. ------_____.. _____ JOB LOCATION: /Y'It/ h1t?r~?;n ~L, *', ' .' ASSESSORS MAP D: /10< ,;tc::;- :J.., ~ .TAX LOT j!. / {) 0 .' . . OIlNER: J;/ a/ tf-"'t:I~ ADDRESS: /~ )" i; 6(5''''/ h?K~ P'r CITY: ~'t/t?///f .STATE: t1,.. PHONE 11: 5''1'1- 7S7- 2 71't1 ZIP :Y'7.77? , NOTICE: BACKFLOll PERMIT IS $15.00 + $.75 (STATETSURCHARGE)'L+.II$..t.SPI(-ADlFrN'EFE&.)Ka $16.20 MlvicnlVllI ;,)nML....[;.1\ .11.... ", "_'. qONT~O;: It/1'r~ /%7~ 7/(g~??~qp,~~:~~~:():~~~:~QNOT " ADDRESS: .11z 1/ 'fr- ANY1E'':;r\YPERI.PHONE 1I: 72~~G.7'ZY' CITY:1","/'?1?}:/t!'t"<< /?r STATE: c?,r ZIP:J?7Y'77 CONSTRUCTION CONTRACTORS REGISTRATION I: /Z-b'tl?5 8XPIRES:k.>-n' BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN IN:,?ECTION ONCE TilE BACKFLOll PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE '.OR INSPECTION (726-3769). I ALSO STATE TIlAT ALL INFORMATION ON TillS PERMIT, ,\PPLICATION IS CORRECT. ~/~//I/ ".L---P____ SIGJ;L:URE. V<o',' r,;" r /-:- Z'J-?,/ 1iA':'i> FOR OFFICE USE ---------.---------------------------- ----- ------------------- -. ----------- - ------ DATE OF /;PPLICATION I tf l $' /11 RECEIPT I': 01 L (, r, { ISSUED BY: JJ'; 6: Qr;'{)!oL/ JW,J' ...L.:L!L - TOTAL AMOUNT COLLECTED: r'. 2-tJ --------..------ -----------------------~---------------------- - -----------.. ------