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_ snrnt 1 r%I%1 rU"dE77 COUNTY <br /> ®)LHR TRANSFER ENEW4 UNIFORM PERMIT # <br /> "J �P{SS (PLB 67• _� 7Qi�3Z <br /> ERitT,T RENE.WAL ATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER. <br /> ro7 S- 3/- o <br /> 'ROPERTY LOCATION: CITY: <br /> SE % NE '/,,S 3 /,T 4o N,R /7 E (Or)dq TOWNOF unfo#1 <br /> OT NUMP,E DIVISION NAME: NEAREST ROAD, LAKE OR LANDMARK: <br /> 90So welch /7.( <br /> PREVIOUS SANITARY PERMIT HOLDER IIF CHANGED): SANITARY PERMIT TRANSFERRED TO: <br /> .AME: SIGNATURE: NAME: PHONE NUMBER: <br /> ;DDRESS: PHONE NUMBER: ADDRESS: <br /> I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this <br /> property. <br /> •LUM1'.B ER SnSIGfdATUH PREVIOUS PLUMBER'S NAME (IF CHANGED): <br /> 'LUMBER'.5GDnF-;,s. PREVIOUS PLUMBER'S ADDRESS. <br /> ,t 7760//, y 3S We&s r. wT S'V r93 <br /> dP;FAPF SW NUM81-ri PHONE NUMBER: MP!MPR.SW NUMBER. PHONE NUMBER: <br /> _ JA_rgsf 715' <br /> i1GNAT 'IF - <br /> Issufjf/�G A.I;W, FATE APFROVFo DISTRIBUTION: Onginei County <br /> Copy -Bureau of Plumbing _ <br /> ._1_—__.._LI CoPYOwner <br /> (R. CnpY Plumber <br />