Permit ..
CITY TI G ARD SEWER CONNECTION PERMIT
'" 14, DEVELOPMENT SERVICES PERMIT #: SWR2004 -00338
Ail: 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 11/2/2004
SITE ADDRESS; 11480 SW FONNER ST PARCEL: 2S103AC -02300
SUBDIVISION: ZONING: R - 4.5
BLOCK: LOT: 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 SF to sewer
Owner:
FEES
KENNETH GERTZ
19200 SW 46TH AVE Description Date Amount
TUALATIN, OR 97062 [SWUSA] Swr Connecti( 11/2/2004 $2,500.00
[SWUSA] Swr Connecti( 11/2/2004 $0.00
Phone: 503- 692 -3390 [SWINSP] Sewer Inspeci 11/2/2004 $35.00
[SWINSP] Sewer Inspect 11/2/2004 $0.00
Contractor:
Total $2,535.00
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"
Permit and the Agency will install a lateral. ATTENTION: Oregon law requires you to follow rules adopted by the
Oregonn Ut otification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You
m ' obtain copies of the - rules or direct questions to OUNC by calling (503) 246 -6699.
1
lss ed by: 1/ .r G/ /444) Permittee Signature: /
— Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day