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P - 75049CITY OF FRtOLEY WATER AND SEWER CONNECTION PER�1�{IT APPLICATION [;. �� r IHom� .� ��: s� / ( LEGAL DESCRIPTION PERMIT: c/- SEYVER: FEE: �� Plumbe�) � _„v� ;_"��'�G`:��i � t n\�� / W / ✓ �ate: �� "�U �9� WATER: �` METER: FEE: I� DD pEPO61T: O-DAPTER: SURCH RGE: � SURCHARGE: �� TOTAL: � TOT/1L: /S S TOTAL: �� / !iG � GRAND TOTAL: � S.A.C. CHARGE ON EXISTING STRUCTURE: EXiSTING STRUCTURE: NEW STRUCTURE: BUIIDING PERMIT No.: a� �� SEWER R T NO.: SPECIAL ASSESSUAEN `- ~ -" Si�ned � c.� ��°l= ! � �� B