Permit CITY TIGARD SEWER CONNECTION PERMIT
ik DEVELOPMENT I SERVICES PERMIT #: S /11/03 -00301
Ail 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 12/11/03
SITE ADDRESS; 15750 SW 98TH AVE ADM. BLDG. PARCEL: 2S111CD -00300
SUBDIVISION: ALDERBROOK FARM ZONING: R -
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME: TIGARD CHURCH OF GOD
USA NO: FIXTURE UNITS: 24
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: 1.5 EDU increase. Previous EDU =5 for a total of 80 fixture values. Addition of 24 fixture values,
for a new total of 104 fixtire values =6.5 current EDU's.
Owner:
FEES
TIGARD CHURCH OF GOD
15670 SW 98TH AVENUE Description Date Amount
TIGARD, OR 97223 [SWUSA] Swr Connect 12/11/03 $3,600.00
[ SWUSA] Swr Connect 12/11/03 $0.00
Phone:
Total $3,600.00
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: k 46 Permittee Signature: � /� beg
Call (503) 9 -4175 by 7:00 P.M. for an inspection needed the next b
Accumulative Sewer Tally
Tenant Name Tigard Church of God This SWRA 2003 -00301
Site Address: j57 -OJW 98th Ave. This PLM# 2003 -00326
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 1 5 1 5
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 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 2 4 2 4
- Bradley 5 • 0 0 0 0 0
- Commercial 3 . 0 0 1. 3 1 3
- Service 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 2 12 • 2 12
Urinal 6 0 0 • 0 0 0
Previous EDU Count 5 80 80
Capped EDU Credit 0
TOTALS 0 80 0 0 6 24 6 104
Current Fixture Value 104 divided by 16 = 6.5 Current EDU 1 EDU = $ 2,400
Previous Fixture Value 80 divided by 16 = 5.0 Previous EDU
Change 24 divided by 16 = 1.5 over (under) $ 3,600.00 .
Enter EDU Change Here 1.5
HISTORY
Previous EDU ct. from water PLM# EDU# SWR#
department/Jaime PLM# EDU# SWR#
PLM# EDU# SWR#
Name: 1i' / //, 4_ ,ay! , Date: –09 —ef7
Signature of person that calculated this tally sheet and date perfromed is required