Permit C ITY OF TI GARD SEWER CONNECTION PERMIT
sr DEVELOPMENT SERVICES PERMIT #: SWR2004 -00266
'�� I-' DATE ISSUED: 9/21/2004
13125 SW Hall B Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS; 15865 SW 72ND AVE BLDG -C PARCEL: 2S112DC -00201
SUBDIVISION: OREGON BUSINESS PARK III ZONING: I -P
BLOCK: LOT: 003 JURISDICTION: TIG
TENANT NAME: CHEMWEST
USA NO: FIXTURE UNITS: 7
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .7 EDU increase.
Owner: FEES
PACIFIC REALTY ASSOCIATES Description Date Amount
15350 SW SEQUOIA PKWY #300 -WMI
PORTLAND, OR 97224 [SWUSA] SwrConnectic 9/21/2004 $1,750.00
[SWUSA] Swr Connectic 9/21/2004 $0.00
Phone: Total $1,750.00
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"
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.
Issued by: A , L Permittee Signature: i i • _
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
1 'X. ' ,,- -- 5,„, -' j t -.:.r,,;. t .,, K Si r.
Accumulative Sewer Tally Parcel # 2S112DC 00201 24 _:. .� 1
Tenant`. dam ,Chem rest Systeirt , ,i • ,;; ,.„ This SW02004 00266 eg:.r ..s Y
Site Address:' 15865`S,W-.72nd : ::',i..' '...:" ' ` ' , This PLM# 2004;00437 � .. , .
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
�, - : ` ' :.4.; 0 0 0
Baptisery/Font 4
Bath - Tub /Shower 4 • 0 0 „ r; 0 0 0
ool 4 - 0 p s'' 0 " '
P ,i ,
- Jacuzzi/Whirlpool 0 0 0
Car Wash - Each Stall 6 0 0 , , A 4 0 0 0
- Drive through 16 ; - .'r ,f.:..; - 0 y 0 z 0 0 0
Cuspidor/Water Aspirator 1 : `' • { w
Dishwasher - Commercial 4 :- :i. 0 0 0 0 0
- Domestic 2 • 0 r k n 0 - 0 0 0
Drinking Fountain 1 0 0 • ,4 ,, Yc 0 0 0
Eye Wash 1 , -' 0 t .V 0 - Mr 0 0 0
Floor Drain /Sink - 2 inch 2 , ,, , ,:::','..;A:, 0 x :V 0 1 o = n ,. 2 1 2
- 3 inch 5 :r 0 0 ; ;" - y4 0 0 0
- 4 inch 6 ,::..
H ,. 0 7 ; ' 0 0 0 0
- Car Wash Dui 6 ,;,7 ,, ,N 0 �Y h 0 r 4 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 s.- 0 ; ,rs 0 } 0 0 0
- Commercial (to 5 HP) 32 M. 0 , ii 0 x F :' 0 0 0
- Industrial (over 5 HP) 4 ` ,1% 0 ,. � '
<
. i,g, s
Ice Machine /Refrigerator Drain 1 e. ,: ; s 0 ;; , `wW; , 0 s z; 4„ :: - ; w'
0 0 0
Oil Sep (Gas Station) 6 . `;. - 0 s ` Ax 0 : ` " ° l 0 0 0
Rec. Vehicle Dump station 16 ::',.;',,',' ..r 0 ; .^ r < 0 ,`. ,;:$ 0 0 0
°.s
Shower - Gang (per head) 1 0 ` f ; : y 0 . ;Fr < 0 0 0
- Stall 2 x .. • 0 ;5 0 { ,. ,, < ;
Sink -Bar /Lavatory 2 0 ;, 0 0 0 0
- Bradley 5 0 g 0 • :,x , 0 0 0
- Commercial 3 ▪ F
- Service 3 -", , z 0 ¢ `"K� 0 0 0 0
Swimming Pool Filter 1 ; n - u;,: .
Washer - Clothes 6 -- a y§ 0 ,�; F' 0 ' 'A . ',f..< 0 0 0
Water Extractor 6 4 : ;
`� 0 '' w 0 ` 0 0 0
Water Closet - Toilet 6}: 0 4 0 F,Z ° € 0 0 0
Urinal 6 . _.:',".� 0 .� : .4r 0 ,, ▪ ; -, :: 6 1 6
Previous EDU Count :`. r.- °. :T- 0 0
Capped EDU Credit r _ r ' 0
TOTALS _ 0 0 0 0 3 11 3 11
Current Fixture Value 11 divided by 16 = 0.7 Current EDU 1 EDU = $ 2,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 11 divided by 16 = 0.7 over (under) $ 1,750.00
Enter EDU Change Here; .10.7;
Notes:
Signature: e1 , d.) Date: �J/ / /DV
Building Division
(Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher
hich must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
i:\Building\Sewer TaIIy\SewerTallySheet.xls 7/1/04