Permit A-rat-rijedZ
CITY TIGARD EWER CONNECTION PERMIT
re" DEVELOPMENT SERVICES PERMIT #: SWR2002 -00305
I I 13125 SW Hall Blv Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 11/19/02
SITE ADDRESS; 16640 SW 72ND AVE B -10 PARCEL: 2S113AD -01900
SUBDIVISION: ZONING:
BLOCK: LOT: JURISDICTION:
TENANT NAME: VERIS
USA NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .4 EDU increase. Previous EDU =67.4 for a total of 1078.4 fixture values. Addition of 18 fixture
values, less a previous CREDIT of .7 EDU (11.2 fix. values) for a new fix. total of 1085.2 =67.8
current EDUs.
Owner: FEES
PACIFIC REALTY ASSOCIATES Description Date Amount
15350 SW SEQUOIA PKWY #300 -WMI
PORTLAND, OR 97224 [SWUSA] Swr Connect 11/19/02 $690.00
[SWUSA] Swr Connect 11/21/02 $230.00
Phone:
Total $920.00
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 copi-. of these rules or dir t questions to OUNC by calling (503) 246 -6699.
/ 70
Issued by: _4//, , _/`./ � /_A
Permittee Signature:
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally
Tenant Name: VV REVISED W/ ADDITIONS This SWR* 2002 -00305
Site Address: 16640 SW 72nd This PLM# 2002 -00446 �_,...
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# yalue 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
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Dr 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 3 6 3 6
- 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 . 0 0 0 0 0
Water Closet - Toilet 6 0 0 2 12 2 12
Urinal 6 0 0 0 0 0
Previous EDU Count 67.4 1078.4 1078.4
Capped EDU Credit 0.7 11.2
TOTALS 0 1078.4 , 0 0 5 18 5 1085.2
Current Fixture Value 1085.2 divided by 16 = 67.8 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 1078.4 divided by 16 = 67.4 Previous EDU
Change 6.8 divided by 16 = 0.4 over (under) $ 920.00
Enter EDU Change Here 0.4
HISTORY
Notes:Previous Credit .7EDU PLM# EDU# SWR#
applied PLM# EDU# SWR#
PLM# EDU# SWR#
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Name: C , .QiJ��if Q , y CLI.��� :r v Date: /7 -„9/ - ) -L—
Signature of person that calculated this tally sheet and date perfromed is required