Permit _ CITY OF TIGARD SEWER CONNECTION PERMIT
'`1 tt ;R COMMUNITY DEVELOPMENT Permit SWR2009 -00021
Date Issued 04/10/2009
TIGARD 13125 SW Hall Blvd , Tigard OR 97223 503 639 4171
Parcel 2S103DD00414
Jurisdiction Tigard
Site address 10820 5W FAIRHAVEN ST
Subdivision Lot 0
Project Winterbourne
Project Description Connect to sewer
FEES
Owner
WINTERBOURNE, JEANI & MICHAEL Description Date Amount
10820 SW FAIRHAVEN ST Sewer Connection Fee 04/10/2009 $3,100 00
TIGARD, OR 97223 Sewer Inspection - Residential 04/10/2009 $35 00
PHONE
Contractor
OWNER
PHONE
FAX
Type of Use SF
Class of Work ALT
Install Type Line Tap and Building Sewer
Fixture Units
Number of Dwelling Units 1
Total $3,135 00
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR Specialty Codes and all other
applicable law All work will be done in accordance with approved plans This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days ATTENTION Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Ce nter D Those rules are set forth in OAR 9 952 -001 -0010 through OAR 952- 001 -0100 You may obtain a copy of the rules
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Issued By js'( 6 it `/k Q c... 0 AJ\ Permittee Signature 4_ 1AA !2 4.1 ��\JJJ"' Call 503 639 4175 by 7 00 a m for an inspection that busint 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
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RECEIVED
jut 2120
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� .: _ ,� =. PO BOX 1130 BUILDLNO D
.. I� WILSONVILLE, on 97070
(503) C®,2020 FAX MOM 0704290
CUSTOMER S ORDER NO a RHI0 DATE 1
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ADDRESS
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C SH C 0 D CHARGE ON ACCT MDSE PET 'DPAID OUT
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1 _ All crows and returned goods MUST be accompanied by This bill -
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CERTIFICATION
RECEIVED
OF JUt 2 1 2009
EXISTING SYSTEM DECOMMISSIONING C ITY OFTIGARD
BUILDWG DIVISION
SEPTIC PERMIT NUMBER: 'l
T. 2 5. R. _ E.; Sec. .3 L)D ; Tax Lot DH t'-4
The street address for the property is 10B/0 D Fn 1 (haven St
By my signature, I certify that the existing (select one or more of the following)
[�1 Septic tank [ ] Seepage Pit [ ] Cesspool
was decommissioned in accordance with established standards of the Department of
Environmental Quality (DEQ) The DEQ standards require the selected items to be:
A) pumped by a licensed sewage disposal pumping service to remove all septage;
B) filled with reject sand, bar run gravel or other material acceptable to the County, OR
the tank must be removed and properly disposed
The septage was pumped by — i [ / as /I ' f i t ' Y " C 1 LLC
(Compan • .me of the septage pu ping business)
Signature: // ZJS Date 16(01 [DID3
• Attach a -opy of the pumping receipt.
• Remit completed form to:
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soils Decom doc 05/23/03