Permit i
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CITY TIGARD SEWER CONNECTION PERMIT
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DEVELOPMENT SERVICES PERMIT #: SWR2004 - 00109
��'i 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 4/1/04
SITE ADDRESS; 12950 SW 129TH PL PARCEL: 2S104AD 03301
SUBDIVISION: ZONING: R -7
BLOCK: LOT: 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: Connect existing residence to sewer lateral. 270' line work.
Owner:
FEES
LORENCE, WALTER P + DEBI D Description Date Amount
12950 SW 129TH PLACE
TIGARD, OR 97223 [SWINSP] Swr Inspect 4/1/04 $35.00
[ SWINSP] Swr Inspect 4/1/04 $0.00
Phone: 503 -524 -5410 [SWUSA] Swr Connect 4/1/04 $2,400.00
[SWUSA] Swr Connect 4/1/04 $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
1 •
4- Issued by: Permittee Signature
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day