Permit A CITY OF T I GA R D SEWER CONNECTION PERMIT
l; DEVELOPMENT SERVICES PERMIT #: SWR2004 -00135
_.� I - 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 5/13/2004
SITE ADDRESS; 12365 SW 121ST AVE PARCEL: 2S103BB -BP002
SUBDIVISION: BROWN PARTITION ZONING: R - 4.5
BLOCK: LOT: 002 JURISDICTION: TIG
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 relocated SF structure.
Owner: FEES
MARTIN T. LUTHER Description Date Amount
13251 SE 126TH AVE
CLACKAMAS, OR 97015 [SWUSA] Swr Connectic 5/13/2004 $2,400.00
[SWUSA] Swr Connectic 5/13/2004 $0.00
Phone: 503- 698 -8931 [SWINSP] Sewer Inspect 5/13/2004 $35.00
[SWINSP] Sewer Inspect 5/13/2004 $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"
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 o• copies • • -se r r.s or direct questions to OUNC by calling (503) 246 -6699.
I 0 Is ued by: ,_ /
:�: jl1_ ,W1 A Permittee Signature:, • iv.
Call (50 639 -4175 by 7:00 P.M. for an inspection needed the next business day