Permit , 0 :,c
CITY TIGARD SEWER CONNECTION PERMIT
A. l DEVELOPMENT SERVICE PERMIT #: SWR2003-00191
I DATE ISSUED: 6/24/03
' 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS; 10820 SW 130TH AVE PARCEL: 1S133AD-02200
SUBDIVISION: ZONING: R -7
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME: WESTGATE BAPTIST CHURCH
USA NO: FIXTURE UNITS:
CLASS OF WORK: ADD DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .4 EDU increase, previous fixture values were 17.6, this permit adds 6 fixture values for a new total
of 23.6.
Owner: FEES
WESTGATE BAPTIST CHURCH Description Date Amount
12930 SW SCHOLLS FERRY RD
TIGARD, OR 97223 [SWUSA] Swr Connect 6/24/03 $920.00
[SWUSA] Swr Connect 6/24/03 $0.00
Phone:
Total $920.00
Contractor:
Phone:
Reg #:
Required Inspections
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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: a � . , -' Permittee Signature A e...., K k
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally
Tenant Name: We "stgate Baptist - Classroom This SWR# 2003 =00191
Site Address: 10820 SW 130th Ave This PLM# 2003 -00274 -
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #s values
Baptisery/Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
- Jacuzzi/Whirlpool 4 0 0 0 0 0
Car Wash - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor/Water Aspirator 1 0 0 0 0 0
Dishwasher - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 0 0 0
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drr 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 HP) 48 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
•
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink - Bar /Lavatory 2 0 0 0 0 0
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
Service 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 1 6 1 6
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 1.1 17.6 17.6
Capped EDU Credit 0
TOTALS 0 17.6 0 0 1 6 1 23.6
Current Fixture Value 23.6 divided by 16 = 1.5 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 17.6 divided by 16 = 1.1 Previous EDU
Change 6 divided by 16 = 0.4 over (under) $ 920.00
Enter EDU Change Here 0.4
HISTORY
PLM# 2003 -00241 EDU# 1.1 SWR# 2003 -00177
PLM# 2002 -00284 EDU# 1 SWR# 2002 -00247
PLM# EDU# SWR#
Na e:^ __iL.. - _'_ I , L Date: (o// 7/�
Signature of person that calculated this tally sheet and date perfromed is required