Permit CITY TIGARD SEWER CONNECTION PERMIT
I + � DEVELOPMENT SERVICES PERMIT #: SWR2005 -00142
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 4171 DATE ISSUED: 4/25/2005
PARCEL: 2S 103AD -00406
SITE ADDRESS; 10915 SW FONNER ST ZONING: R - 5
SUBDIVISION: LOT: 013 JURISDICTION: TIG
Project Description: Sewer connection for existing house.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS:
TYPE OF USE: SF NO. OF BUILDINGS: 1
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner: FEES
ROUTON, CLYDE A
ROUTON, ETTA M TRUSTEE Description Date Amount
10915 SW FONNER [SWUSA] Swr Connection Fee 4/25/2005 $2,500.00
TIGARD, OR 97223 [SWINSP] Sewer Inspection Fee 4/25/2005 $35.00
Phone: 503 639 - 3365 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 obtain copies of these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issued by: q‘, � � %> Permittee Signature: k� -).6c2.1a- ,
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.