Permit A CITY OF TIGARD SEWER CONNECTION PERMIT
k DEVELOPMENT SERVICES PERMIT #: SWR2002-00294
GJI 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 11/4/02
SITE ADDRESS; 14617 SW 126TH AVE PARCEL: 2S109AD -10200
SUBDIVISION: ZONING:
BLOCK: LOT: JURISDICTION:
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
MATT CRINO
3 MONROE PKWY STE P Description Date Amount
PMB 335 [SWUSA] Swr Connect 11/4/02 $2,300.00
LAKE OSWEGO, OR 97035 [SWINSP] Swr Inspect 11/4/02 $35.00
Phone: 503 244 - 0052
Total $2,335.00
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" Perm
Issued by: 4f, ` „ / �_„� Permittee Signature: / //
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day