Permit _ • •
C ITY OF TI GARD SEWER CONNECTION PERMIT
i k DEVELOPMENT SERVICES PERMIT #: SWR2004 -00406
VII 13125 SW H all Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 1/4/2005
SITE ADDRESS; 15895 SW 72ND AVE BLDG B 250 PARCEL: 2S112DC -00500
SUBDIVISION: FANNO CREEK ACRE TRACTS ZONING: I -P
BLOCK: LOT: 040 JURISDICTION: TIG
TENANT NAME: DR DAVID KAO
USA NO: FIXTURE UNITS: 8
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: add 1.1 edu's.
Owner: FEES
PACIFIC REALTY ASSOCIATES Description Date Amount
15350 SW SEQUOIA PKWY #300 -WMI
PORTLAND, OR 97224 [SWUSA] Swr Connectic 1/4/2005 $2,640.00
[SWUSA] Swr Connectic 1/4/2005 $0.00
Phone:
Total $2,640.00
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 b L
Y ,
: , Permittee Signa �%' ICI c h A
�C �
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed t _ next business day
y Accumulative Sewer Tally Parcel # ,2S1�12DC; 00,500 5 3� , }
1 nantN , Davi Ka ,i,: fi h „ _ F hi This SW R #x2004 =00406 'K'"` ",, : / '' ; fi. ,fi 'Y
ter..
sSite Addiess;.'1'5895 SW 72rld Ave# 250 ,. . t. ,,, '..,.<. This PLM# 2004X00565 ,; ; '
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
; � , y, 0 c ,4 . 0 0 0
r _ , F >_ �. Ufa a, ...,; ,, r
Bath -Tub /Shower 4 � 0 d` & 0 „; ` , ' ;•
0
x 0 0 0
- Jacuzzi/Whirlpool 4 ; ,'� ='y; °�5�� %� °�� 0 t�,
Car Wash - Each Stall 6 ra ;Tt . ` 0 7 't 0 •z T, - ;; 0 0 0
- Drive through 16 s { 0 0 r 0 0 0
Cuspidor/Water Aspirator 1 0 0 -5 , M:. 0 0 0
Dishwasher - Commercial 4 , .' .. 0 0 ' s, ;± 0 0 0
- Domestic 2 >. °' fl ; 0 0 '��' ? 0 0 0
Drinking Fountain 1 ,, ; ". -.,4; 0 .,, .?:. " .." 0 `` 0 0 0
Eye Wash 1 : ;s- %zw. 0 'il, 5 ti 0 <. ry
Floor Drain /Sink - 2 inch 2 M,. ' , 0 ' G x 'X,k 0 a 0 0 0
- 3 inch 5 t�` a 0 } 0 4 , . 0 0 0
- 4 inch 6 ' ?' 0 n y 0 '%',-,,,J 4 0 0 0 • - Car Wash Dm 6 •' 0 0 ' * r' 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 ' F r 0 , as ' . ' ''. 0 sz 0 0 0
- Commercial (to 5 HP) 32 . x� 0 `a ?,, , „ 0 s , ” - , 4 z 0 0 0
- Industrial (over 5 HP) 48 .t:; °,. 0 ,, ; ,,,. 0
Ice Machine /Refrigerator Drain 1 «ti5' - 4 0 ;':,,. �? ` 0 .19i:•, " 0 0 0
Oil Sep (Gas Station) 6 ,x 1 41- 7 ' 0 w 0 . z' 0 0 0
Rec. Vehicle Dump station 16 i - 0 x f. ? ,. 0 u , n . >�; ,;; ii 0 0 0
Shower - Gang >x:y'w ' , # r,
g (per head) 1 -� .. 0 _;� °,'� 0 44iiel 0 0 0
- Stall 2 f 0 e A ; r 0 ,.. z' 0 0 0
Sink -Bar /Lavatory 2 <, 04 0 k 1 ,2- 0 0 0
- Bradley 5 i 0 4 s 0 „ 0 0 0
- Commercial 3 = ; , 0 f 0 „ z. 0 0 0
- Service 3 y u ; 0 0 6 ` 18 6 18
Swimming Pool Filter 1 x r 0 , ' ` "' -q,:' 0 0 0 0
Washer - Clothes 6 ' a "*, t 0 may' . 0 ' Xt< t.r 0 0 0
Water Extractor 6 F ''r�: ', 0 aX K ;; 0 v 0 0 0
Water Closet - Toilet 6 �,_ 0 ,
Urinal 6 ,; ` 2 . a 0 f 5 ^r= 0 i, ?, , w >� 0 0 0
Previous EDU Count :' '). ,, �' �x
' ? 0 0
Capped EDU Credit h , ° , , 0
TOTALS 0 0 0 0 6 18 6 18
Current Fixture Value 18 divided by 16 = 1.1 Current EDU 1 EDU = $ 2,400
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 18 divided by 16 = 1.1 over (under) $ 2,640.00
Enter EDU Change Here ;;;: 1,;1;v`r
Notes:
Signature: id.'r,a,/i_ct,6.,_ i Date: -05"
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\SewerTally\SewerTallySheet.xls 11/19/03