Permit CITY OF TIGARD SEWER CONNECTION PERMIT
"�1 = COMMUNITY DEVELOPMENT Permit#: SWR2021-00279
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 11/17/2021
Parcel: 2S 102CB02300
Jurisdiction: Tigard
Site address: 13240 SW PACIFIC HWY
Project: Westside Surgery Center Subdivision: FREWING'S ORCHARD TRACTS Lot: 8
Project Description: 1.81 EDU increase.
Contractor: Owner: WESTSIDE BUILDING PROPERTIES LLC
BY VALLABHANATH, PRASHANTH
11086 SE OAK ST
MILWAUKIE, OR 97222
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 11/17/2021 $11,013.85
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: 1.81
Total $11,013.85
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
Issued By: Permittee Signature: f.
Call 503.639.4175 by 7:00 a.m.for the next available inspection date. �/ L
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
III 14 Accumulative Sewer Tally
i 'Tenant Name: WESTSIDE SURGERY CENTER SWR# 2021-00279
TIGARD Site Address: 13240 SW PACIFIC IIWY PLM# 2021-00344
Parcel#: 2S102CB02300
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value total#s total values
Baptistry/Pont 4 0 0 0 0 0
Bath: -Tub/Shower 4 0 0 0 0 0
-Jacuzzi/Whirlpool 4 0 0 0 0 0
Car Wash: -Each Stall 6 0 0 0 0 0
-Drive through 16 0 0 0 0 0
Cuspidor/Water Aspirator 1 0 0 0 0 0
Dishwasher: -Commercial 4 0 0 0 0 0
-Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 1 1 1 1
Floor Drain/Sink: -2 inch 2 0 0 0 0 0
-3 inch 5 0 0 0 0 0
-4 inch 6 0 0 1 6 1 6
-Car Wash 6 0 0 0 0 0
Garbage Disposal:
-Domestic(to 3/4 IIP) 16 0 0 0 0 0
-Commercial(to 5 HP) 32 0 0 0 0 0
-Industrial(over 5 IIP) 42 0 0 0 0 0
Ice Machine/Refrigerator Drain 1 0 0 0 0 0
Living Unit 16 0 0 0 0 0
Oil Sep(Gas Station) 6 0 0 0 0 0
Rec.Vehicle Dump station 16 0 0 0 0 0
Shower: -Gang(per head) 1 0 0 0 0 0
-Stall 2 0 0 1 2 1 2
Sink:
-Lav/Bar-Non-Food Related 2 0 4 8 8 16 4 8
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 0 2 6 2 6
Swimming Pool Filter 1 0 0 0 0 0
Washer-Clothes 6 0 1 6 0 -1 -6
Water Extractor 6 0 0 0 0 0
Water Closet-Toilet 6 0 0 2 12 2 12
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
1OTA1,S 0 0 5 14 15 43 10 29
Current Fixture Value 29 divided by 16= 1.813 Current EDU 1 EDU= $6,085.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 29 divided by 16= 1.813 over (under) S 11,013.85
Enter EDU Change Here 1.810
*Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01.
Notes:
Authorized Name/Signature: BRANDEN T'AGGAR'I'X2449 Date: 10/28/2021
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist,this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
I:ABuilding\Sewer Tally ASewer 1'allySheet_6085_070121.xksx