Permit - CiTY OF TIGARD SEWER CONNECTION PERMIT
�r DEVELOPMENT SERVICES PERMIT #: SWR2002 -00303
I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 1/2/03
SITE ADDRESS; 12750 SW 68TH AVE PARCEL: 2S101AD -01300
SUBDIVISION: WEST PORTLAND HEIGHTS ZONING: MUE
BLOCK: LOT: 033 JURISDICTION: TIG
TENANT NAME: DR SORENSON
USA NO: FIXTURE UNITS: 44
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: 2.8 EDU increase. Previous EDU =2 for a total of 32 fixture values. Addition of 44 fixture values,
for a new total of 76 fixture values =4.8 current EDUs.
Owner:
FEES
HAMPTON BUILDING, THE LLC
6803 SW WHEATLAND RUN Description Date Amount
WILSONVILLE, OR 97070 [SWUSA] Swr Connect 1/2/03 $6,440.00
[SWUSA] Swr Connect 1/2/03 $0.00
Phone:
Total $6,440.00
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
/ l •
Permittee Signature: J L v k,
Call (503 - 9-4175 by 7:00 P.M. for an inspection needed the next „ usiness d
Accumulative Sewer Tally
Tenant Name: Pacific Dental Institute This SWRil 2002 -00303
Tenant Name: 12Thirga8th Pkwy. This PLM# 2002 -00428
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 1 4 0 -1 -4
- 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
- 3 inch 5 0 3 15 2 10 -1 -5
- 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 1 1 1 1
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 - Bar /Lavatory 2 0 3 6 4 8 1 2
- Bradley 5 0 0 0 0 0
- Commercial 3 0 1 3 13 39 12 36
- Service 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 1 6 1 6
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 3 18 4 24 1 6
Urinal 6 0 0 0 0 0
Previous EDU Count 2 32 32
Capped EDU Credit 0
TOTALS 0 32 11 46 26 90 15 76
Current Fixture Value 76 divided by 16 = 4.8 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 32 divided by 16 = 2.0 Previous EDU
Change 44 divided by 16 = 2.8 over (under) $ 6,440.00
Enter EDU Change Here 2.8
HISTORY
EDU CT. OF 2 FROM WATER PLM# EDU# SWR#
DEPARTMENT. PLM# EDU# SWR#
Sewer tally provided by MS PLM# EDU# SWR#
Name: K�/lf.2,.� ,, .r �.� Date: 1/ — / 5/ -0 a
Signature of person that calculated this tally sheet and date perfromed is required