Permit CITY TIGARD SEWER CONNECTION PERMIT
eo DEVELOPMENT SERVICES PERMIT #: SWR2003 -00326
s' " DATE ISSUED: 8/14/03
II 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
/..25 PARCEL: 2S 101 AA -08700
SITE ADDRESS; 4565 SW 68TH AVE
SUBDIVISION: WEST PORTLAND HEIGHTS ZONING: MUE
BLOCK: LOT: 029 JURISDICTION: TIG
TENANT NAME: HEINTZBERGER
USA NO: FIXTURE UNITS: 4
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .3 EDU increase . Previous EDU 2.5 for a fixture count of 40. addition of 4 fixture
count increase to 44 fixture count for increase of .3 EDU's.
Owner: FEES
HEINTZBERGER Description Date Amount
12600 SW 72ND AVE, STE 200
TIGARD, OR 97223 [SWUSA] Swr Connect 8/14/03 $720.00
[ SWUSA] Swr Connect 8/14/03 $0.00
Phone: Total $720.00
Contractor:
Phone:
Reg #:
Required Inspections
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" Perm
Issued by: � ' / A, Permittee Signature:_ W
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next bus'; s day
Accumulative Sewer Tally
Tenant Name: 14irittfirger This SWRt 2003 -00326
Site Address: 68th Ave. This PLM# 2003 -00419
las
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 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 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 0 0 0
-3inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 HP) 48 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 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 0 0 0
Sink - Bar /Lavatory 2 0 0 .2 4 2 4
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 0 0 • 0 0 0
Previous EDU Count 2.5 40 40
Capped EDU Credit 0
TOTALS 0 40 0 0 2 4 2 44
Current Fixture Value 44 divided by 16 = 2.8 Current EDU 1 EDU = $ 2,400
Previous Fixture Value 40 divided by 16 = 2.5 Previous EDU
Change 4 divided by 16 = 0.3 over (under) $ 720.00
Enter EDU Change Here 0.3
HISTORY
Previous: Yellow file. PLM# EDU# SWR#
PLM# EDU# SWR#
PLM# EDU# SWR#
Name: , r „& Date: ,g- -0 3
Signature of person that calculated this tally sheet and date perfromed is required