Permit liq CITY OF TIGARD SEWER CONNECTION PERMIT
° COMMUNITY DEVELOPMENT PERMIT #: SWR2006 - 00218
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 10/3/2006
PARCEL: 25101 AA -09700
SITE ADDRESS: 12587 SW 68TH AVE ZONING: MUE
SUBDIVISION: PP1996 - 024 LOT: 001 JURISDICTION: TIG
Project Description: .9 EDU increase. 11/28/06 changed address (from 12585 68th Ave)
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0.9
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner:
MARK NIELSON FEES
7150 SW HAMPTON Description Date Amount
STE. #228
TIGARD, OR 97223 [SWUSA] Sewer Connection Fee 10/3/2006 $2,430.00
Phone: 503 - 582 -5777
Total $2,430.00
Contractor:
Contact #: REQUIRED ITEMS AND REPORTS
Reg #:
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180 days from the
date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side
sewer laterals. If the sewer is not located at the measurement given, the installer shall prospect 3 feet in all directions from the distance
given. If not so located, the installer shall purchase a "Tap and Side Sewer" Permit and the Agency will install a lateral. ATTENTION:
Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling 503.246.6699
or 1.800.332.2344.
Issued by: Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
Accumulative Sewer Tally Parcel # r2W:(40741::;;SEgragrA
t646444.5 This SW R0005027102VTX:'
',SiteYAd,orkeii:OietifS)&56,TWAW;ZMIAPANMAR This PI-M#1200,00420,MOMMI:MN
4
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #s values
Baptisery/Font 4 e,:.5: 0 , ,,,ivom 0 ,,,,,,,,,
4„,.„: 0 0 0
Bath - Tub/Shower 4 `: 0 nitM, 0 M:Argl
z 0 0 0
Jacuzzi/Whirlpool 4 - '-.e.1"IA1,,i , 1 0 taati 0 ;V:zRi,,W'M
0,43%.W 0 0 0
Car Wash - Each Stall 6 0 Aga 0 .2011. 0 0 0
- Drive through 16 .]:., On 0 new 0 =NM 0 0 0
Cuspidor/VVater Aspirator 1 0 t:Zr:,il 0 eatow 0 0 0
Dishwasher - Commercial 4 `,-'':.! 0 td- eAtV: 0 Y 0 0 0
.. .=, 1 ,:,
- Domestic 2 4 0 ,,,,,,,,,..,,,:" 0 .;< 0 0 0
,,,,An 0 ,44..<„.>" ,
Drinking Fountain 1 :. , n4.k' eA33 v .:&;: 0 a 4.. 4 0 0 0
Eye Wash 1 ,Lz:' 0 " 0 '-`1i;Y'?V:,',M 0 0 0
Floor Drain/Sink - 2 inch 2 Mati 0 ,tfiti a 2 dga0 0 A -2
" .;',? 0 agia
- 3 inch 5 It.',.; .;,.. 40 0 4. 0 0 0
- 4 inch 6 ,a1011 0 ,; ii*:.i':71E.: . : . v,. o 0 0
- Car Wash Drr 6 0 :.' 0 greal 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 siT.::;:21 0 ktiell, 0 :;.7: .1%..:::;:a 0 0 0
,,,,,-.. .$.;i. 0 ::',
- Commercial (to 5 HP) 32 4„ :41, 0 oikt.:.", ,, : • •-evis 0 0 0
- Industrial (over 5 HP) ..4a~' 4
42 agt22 0 )
',,,:,;,.*•:;.,'-'" ...1!.24. -4.-..41v,., .,..€
0 ,i.0.44';: ..Q 0 0 0
Ice Machine/Refrigerator Drain 1 '.:.:..:, 1E 0 Ot .4.::3 ;:i:, 0 Nr, .,..1.K:$:. 0 0 0
Oil Sep (Gas Station) 6 :$'S ,'1411:. 0 00 0 0 0 0
Rec. Vehicle Dump station 16 flI:.: 0 4....W4 0 41". 0 0 0
Shower - Gang (per head) 1 M:. 0 i 0 4;r:it ..a 0 0 0
- Stall 2 :V.'''.r: .. ' 0 giri;,..Pe.: 0 •:::::::::•mg
':••:e.:*;!: ur 0 0 0
, .... >4..,k :•,- 4 %'`
Sink - Bar/Lavatory 2 wt n 0 k'::::ti;::::"(,i 0 mswg: Y7 . 4 2 4
Bradley g4s)r ,, &oe'T
5 :Iveree 0 T:'.1:0!'1. : 0 11 0 0 0
• ...p.$:: -,,
- Commercial 3 0 :'4 0
Igr 0 0 0
Service 3 :1•1 0 ::. ;;".:." 44;i; A: 0 ni. Sit .,:i; 0 0 0
Swimming Pool Filter 1 !`a4:''7' 0 OM% 0 1'g'` :':-,5 0 0 0
Washer - Clothes 6 nT...,, etz 0 1,1'., :,01 0 , 'XVI 0 0 0
Water Extractor 6 ISM 0 MMif 0 0 0 0
Water Closet - Toilet 6 416,,W.. 0 .: 0 . V0,151,11 12 2 12
Urinal 6 %.:.?.jiiriPiti 0 li.,1:>:,14-% 0 ,.--...,;• 0 0 0
Previous EDU Count g:;% 0 0
Capped EDU Credit 0
TOTALS 0 0 1 2 4 16 3 14
Current Fixture Value 14 divided by 16 = 0.9 Current EDU 1 EDU = $ 2,700
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 14 divided by 16 = 0.9 over (under) $ 2,430.00
Enter EDU Change Here
Notes:
Authorized Name/Signature: :V,;:l'P ,:,,.! Date: . ;';:',-,,Z'41 , 12l2(1601::
Building Division
l 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:\Building\Sewer Tally\SewerTallySheet.xls 7/1/06