Permit V.,
CITY TIGARD SEWER CONNECTION PERMIT
lr� DEVELOPMENT SERVICES PERMIT #: SWR2003 -00220
�� 1 3125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 8/28/03
SITE ADDRESS; 16056 SW 93RD AVE PARCEL: 2S114AB-15300
SUBDIVISION: WILLIAMS PART /MLP2002 - 00011 ZONING: R - 4.5
BLOCK: LOT: 001 JURISDICTION: T1G
TENANT NAME:
USA NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: Sewer connection for new SF.
Owner: FEES
JEFF BETTINELLI
14780 SW OSPREY DR Description Date Amount
SUITE 240 [SWUSA] Swr Connect 8/28/03 $2,400.00
BEAVERTON, OR 97007 [SWUSA] Swr Connect 8/28/03 $0.00
Phone: 503- 201 -6304 [SWINSP] Swr Inspect 8/28/03 $35.00
[ SWINSP] Swr Inspect 8/28/03 $0.00
Contractor:
Total $2,435.00
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
IL : �i �1�
Issu:d by:I l� . /�CJ�� Permittee Signature: Ad/ '
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next • Si p ess day