Permit CITY TIGARD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2003 -00121
— 13125 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 4/21/03
SITE ADDRESS; 07501 SW DARTMOUTH ST 100 WINCO PARCEL: 1S136DC-04500
SUBDIVISION: PP1995 - 013 ZONING: C -
BLOCK: LOT: JURISDICTION: TIC
TENANT NAME: WINCO FOODS
USA NO: FIXTURE UNITS: 404
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .3 EDU increase. Previous EDU =25 for a total of 400 fixture values. Addition of 4 fixture values,
for a new total of 404 fixture values = 25.3 current EDUs.
Owner:
FEES
WAREMART INC
BY BURKE + NICKEL Description Date Amount
3336 E 32ND ST #217 [SWUSA] Swr Connect 4/21/03 $690.00
TULSA, OK 74135 [SWUSA] Swr Connect 4/21/03 $0.00
Phone:
Total $690.00
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: r if(j j�L G� � Permittee S ignature: Ls/4g ii
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally
Tenant Name: Winco Foods This SWR/ 2003 -00121
Address: 7501 SW Dartmouth Rd. Ste. 100 This PLM# 2006 -00134
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 1 4 0 -1 -4
- 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 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 25 400 400
Capped EDU Credit 0
TOTALS 0 400 1 4 2 8 1 404
Current Fixture Value 404 divided by 16 = 25.3 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 400 divided by 16 = 25.0 Previous EDU
Change 4 divided by 16 = 0.3 over (under) $ 690.00
Enter EDU Change Here 0.3
HISTORY
Current EDU 25 per Jamie G. PLM# EDU# SWR#
PLM# EDU# SWR#
PLM# EDU# SWR#
Name: 411.-- h - 42.2:1(/U Date: 1 - - /O -o3
Signature of person that calculated this tally sheet and date perfromed is required