Permit . -
• r CITY OF TIGARD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2005 -00046
t 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 2/18/2005
SITE ADDRESS; 11865 SW CARMEN ST PARCEL: 2S103BD 01900
SUBDIVISION: CARMEN PARK ZONING: R - 4.5
BLOCK: LOT: 012 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 house to newly installed sewer service. Reimbursement District #25 fees paid on
this date.
Owner:
FEES
IADANZA, NICHOLAS E AND
MARGRET A Description Date Amount
11865 SW CARMEN ST [SWUSA] Swr Connectic 2/18/2005 $2,500.00
TIGARD, OR 97223 [SWUSA] Swr Connecti( 2/18/2005 $0.00
Phone: 503 -590 -5239 [SWINSP] Sewer Inspect 2/18/2005 $35.00
[ SWINSP] Sewer Inspect 2/18/2005 $0.00
Total $2,535.00
Contractor:
REQUIRED ITEMS AND REPORTS
Phone:
Reg #:
•
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 ob . •ies of these rules or direct questions to OUNC by calling (503) 246 -6699.
lssu d by: i i , ..-.. � Permittee Signature: ,
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day