Permit CITY TIGARD SEWER CONNECTION PERMIT
PERMIT #: SWR2004 00099
lA, D EVELOPMENT SERVICES
---- ' 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 4/21/04
SITE ADDRESS; 12610 SW BAILEY TERR PARCEL: 2S104BC -BW007
SUBDIVISION: BAILEY WOODS ZONING: R -
BLOCK: LOT: 007 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: Sewer connection for new SF
Owner: FEES
BUENA VISTA CUSTOM HOMES INC Description Date Amount
6932 SW MACADAM AVE STE C
PORTLAND, OR 97219 [SWUSA] Swr Connect 4/21/04 $2,400.00
[SWUSA] Swr Connect 4/21/04 $0.00
Phone: 503- 443 -6033 [SWINSP] Swr Inspect 4/21 /04 $35.00
[SWINSP] Swr Inspect 4/21/04 $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
Issued Q�( ,Lit,` Permittee Signature: X Al
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next b iness ay lii