Permit I CITY OF TIGARD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2005 -00318
9.J � . 13125 SW Hall Blvd., Tigard, O 97223 503 - 639 -4171 DATE ISSUED: 11/8/2005
PARCEL: 2S110BC -00900
SITE ADDRESS: 12475 SW BULL MOUNTAIN RD ZONING: R -1
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: 2.5 EDU increase.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 2.5
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
TIGARD WATER DEPT.
8777 SW BURNHAM ST Description Date Amount
TIGARD, OR 97223 [SWUSA] Sewer Connection Fee 11/8/2005 $6,500.00
Total $6,500.00
Phone: 639 - 4171 395
Contractor:
HAMPTON PLUMBING CO.
411 S COLLEGE ST
NEWBERG, OR 97132
REQUIRED ITEMS AND REPORTS
Phone: 503 -538 -5629
Reg #: LIC 160927
PLM 36 -102PB
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"
Permit and the Agency will install a lateral. ATTENTION: Oregon law requires you to follow rules adopted by the
Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You
may obtain copies of these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issued by: 4,1_,,,-,,, ,,,":"&,. Permittee Signature: el-1. . Ce-4-11 c - -
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Accumulative Sewer Tally Parcel # 1511`0BC -00506
Tenant Name:. Tigard ASR 2 Well Hous ,,, y , ,..,, ,,,, This SWR;42005 -00318 . ,
Site Adt"ress ;2'475 SW Bull Mountain R ' �„ e 4 `?'" ' . This PLM# F O05 -00506 , ,
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 ,x 0 0 0 0
Bath - Tub /Shower 4 '�` 0 5 u 0 0 0 0
- Jacuzzi/Whirlpool 4 l .: 0 0 0 0 0
G,.
Car Wash - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor/Water Aspirator 1 x V 0 0 0 0 0
Dishwasher - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 S 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 1 1 1 1
Floor Drain /Sink - 2 inch 2 0 -, ' 0 0 0 0
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 6 36 6 36
- 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) 42 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 2 0 0 0 0
- 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 s�:' 0 0 0 0
Washer Clothes 6 0 01'. 0 0 0 0
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 it r 0 0
Capped EDU Credit n � ', 0
TOTALS 0 0 0 0 8 40 8 40
Current Fixture Value 40 divided by 16 = 2.5 Current EDU 1 EDU = $ 2.600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 40 divided by 16 = 2.5 over (under) $ 6,500.00
Enter EDU Change Here 2.5
Notes:
Authorized Name /Signature ' K alThtter ; :; Date ` '
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher
which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
i:\Building\Sewer Tally \SewerTallySheet.xls 7/1/05
CITY OF TIGARD
Journal Entry Form JE # 417
G/L # 4 JE Date: 11/7/2005
Description: City of Tigard
Sewer Permit
ASR Well - 2
Month Ending: 10/31/05 Reviewed By:
Entered By: pah Date Entered:
Debit( +) Additional
Ln# Account # Credit( -) Amount Information Trn#
1 530 - 0000 - 101000 - 6,500.00 SWR Permit 2005- 00318/ASR Well -2
2 530 - 6270 - 755515 + 6,500.00 SWR Permit 2005- 003181ASR Well -2
3 500 - 0000 - 101000 + 6,500.00 SWR Permit 2005 -00318 /ASR Well -2
4 500 - 0000 - 207000 - 6,500.00 SWR Permit 2005- 00318 /ASR Well -2
5
6
7
8
9
10
11 + 13,000.00
12 - 13,000.00
13 = 0.00
14
15
16
20
21
22
23
24
25
26
27
28
29 I: \FIN \Financial Operations \EXCEL \JOURNALS \05 -06 FY\[2005- 10.xls]O4JE #417
30_ COPY
11/7/2005
Fees Associated With 3:12:45PM
Case #: SWR2005 -00318
City of Tigard
Fee Start End Revenue Created
Type Date Date Dept Description Account Number By Date Amount Due
PRMT 1/1/1990 12/31/2005 [SWUSA] Sewer Connection Fee 500- 0000 - 207000 BB 10/7/2005 6,500.00 6,500.00 ,
Total: $6,500.00
Sao 2 77 -
Xa�Bv
Dock
Page 1 of 1 CaseFees..rpt
Accumulative Sewer Tally Parcel # 1S110BC -00506 •
Tenant Name: Tigard ASR 2 Well House This SWR# 2005- 00318
Site Address: 12475 SW Bull Mountain R. This PLM# 2005 -00506
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 1 1 1 1
Floor Drain /Sink - 2 inch 2 0 0 0 0 0
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 6 36 6 36
- 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) 42 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 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 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 8 40 8 40
Current Fixture Value 40 divided by 16 = 2.5 Current EDU 1 EDU = $ 2,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 40 divided by 16 = 2.5 over (under) $ 6,500.00
Enter EDU Change Here 2.5
Notes:
Authorized Name /Signature:? Barbara Butler Date: 10/7/2005
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher
which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
is \Building \Sewer Tally \SewerTallySheet.xls 7/1/05