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HomeMy WebLinkAboutPermit Backflow Test 1999-1-25 . sttkFIELD " " ASSESSORS HAP ft: OIINER: ''t(;../ Iff ADDRESS: / n 5 E CITY: . &I/d/~'r BACKFLOIl PREVBNTfmfIO>>l1irellgil'~!\K~re<NlllkI}(ftttlP: I . f~rfiS~~~\\Qe Oregon Utility ~ BWlliD'11f13;nW~r. -m;y~M1Ys are set forth In OAR 952-001-0010 through OAR 952-001- 225 FIFTH.. STREET 0090. You may obtain copies of ,.!F~ICE: 726-' ~:~:~~:::~~-~~-~::::_---------ng~~~~},~~1ic~~!~~oJ~~~ett~~~~I_::~:~__::~=::!~_ : .. .. m er or l e, vrejl?n UlIhty NOllfication JOB LOCATION: ZI Z 2- I11q/,?,#~ljfl~'2344). /10) ;2:;2 <. ,TAX LOT j!: / '!) () ma,d trv("M / I 4r;f e' ,a.. STATE: tf'/' PHONE ft: )'r/- 757- 27f'e' ZIP:?/7YJ BACKFLOIl PERMIT IS $15.00 + $.75 (STATE SURCIIARGE) + $.45 (ADl" eN. FEE) = $16.20 NOnCE: CONTRA,CTO!'i: ~dl-t'/' /-/.:?"v- ~~l:YP~/TP~ll EXPIRE IF THE WORK . .' .' o"? /.V AU I H()RIZED UNDER THIS P~-!M:;T JiUII7.r ADDRESS: 7/(_ <'{-- M....~,,^~_ M l'~ONE ft: .<yfr'lY'fi??' . ~ ~ _......-..~-~ V" ,::i A!:lANu Ncu r-UN . CITY: )AN/7Q,h-i!/L PSTATE:n,o#,I;:'R/nn ZIP:1'7Y77 , I CONSTRUCTION CONTRACTORS REGISTRATION D: /2,{ t:J 7.5 EXPlRES:~~~ BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN IN::?ECTION ONCE TilE BACKFLOIl PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE 'JR INSPECTION (726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TillS PERMIT. :\PPLICATION IS CORRECT. V~~///~ s . , . r /~75 -f' f' I5A'.1:: FOR OFFICE USE ---------.---------------------------------------------------_. ------------------ DATE OF J;PPLICATION: 1/ Lr / 97 , RECEIPT I': ~ J z.~!-2.. ISSUED BY: TOTAL AMOUNT COLLECTED: /6. 2c.J J):i D: c;Cj 6 / () c:. J t.JJ ' --------..-----------------------------~----------____________ h ___________.. ______