Permit CITY TIGARD SEWER CONNECTION PERMIT
i ; DEVELOPMENT SERVICES PERMIT #: SWR2001 -00306
'I° 13125 SW Hall Blvd., Tigard, OR 9 (503) 639 -4171 DATE ISSUED: 11/20/01
SITE ADDRESS; 12660 SW 121ST AVE PARCEL: 2S103BD -01300
SUBDIVISION: ZONING: R -4.5
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME:
USA NO: FIXTURE UNITS:
CLASS OF WORK: DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: Sewer connection. Paid reimbursement district #18 fees of $6,000.00.
Owner:
FEES
BERGQUIST, R KELLY
MERRILL M Type By Date Amount Receipt
12660 SW 121ST PRMT CTR 11/20/01 $2,300.00 27200100000
TIGARD, OR 97223 INSP CTR 11/20/01 $35.00 27200100000
Phone: Total $2,335.00
Contractor:
Phone:
Reg #:
Required Inspections
Sewer Inspection
This Applicant agrees to comply with all the rules and regulations of the Unified Sewage Agency. 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
Issued by /�) Permittee Signature
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Call (50 63 175 by 7:00 P.M. for an inspection needed the next business day