Permit Iv T
CITY TIGARD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2003 -00159
I II 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 5/16/03
SITE ADDRESS; 13221 SW 68TH PKWY PARCEL: 2S101 DA -00102
SUBDIVISION: TRIANGLE CORPORATE PARK ZONING: MUE
BLOCK: LOT: 002 JURISDICTION: TIG
TENANT NAME: HEALTH NET
USA NO: FIXTURE UNITS: 5
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .5 EDU increase. Previous EDU = 34.8 for a total of 556.8 fixture values. Addition of 5 fixture
values, for a new total of 563.8 fixture values = 35.1 current EDUs.
Owner:
FEES
TIGARD TRIANGLE I LLC Description Date Amount
4650 SW MACADAM AVE STE 220
PORTLAND, OR 97201 [SWUSA] Swr Connect 5/16/03 $1,150.00
[SWUSA] Swr Connect 5/16/03 $0.00
Phone: Total $1,150.00
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
d by: Pe rmittee Signature: Issue Y �/y r(� 9 QaMM W
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally
Tenant Name' H ealth Net This SWRt 2003 -00159
Address: 13221 SW 68th Parkway Ste.41frA This PLM# 2003 -00195
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 1 2 1 2
- 3 inch 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 0 0 0
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 3 0 0 1 3 1 3
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 34.8 556.8 556.8
Capped EDU Credit 0
TOTALS 0 556.8 0 0 2 5 2 561.8
Current Fixture Value 561.8 divided by 16 = 35.1 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 556.8 divided by 16 = 34.8 Previous EDU
Change 5 divided by 16 = 0.3 over (under) $ 1,150.00
Enter EDU Change Here 0.5
HISTORY
EDU count from yellow folder PLM# EDU# SWR#
Water dept. not current. PLM# EDU# SWR#
PLM# EDU# SWR#
. . `iL. i _ .
Name: t Date: .5 3 ---0, -3
Signature of person that calculated this tally sheet and date perfromed is required