Permit CITY TIGARD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2004 -00046
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 2/6/04
SITE ADDRESS; 10215 SW HALL BLVD PARCEL: 1S135AA 01400
SUBDIVISION: METZGER ACRE TRACTS ZONING: C - N
BLOCK: LOT: 037 JURISDICTION: TIG
TENANT NAME: INTEGUMEND
USA NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .8 EDU increase.
Owner: FEES
INTEGUMEND
10215 SW HALL BLVD Description Date Amount
TIGARD, OR 97223 [SWUSA] Swr Connect 2/6/04 $1,920.00
[SWUSA] Swr Connect 2/6/04 $0.00
Phone: 503- 245 -2415
Total $1,920.00
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
Permittee Signature
Call (503 639 -4175 by 7:00 P.M. for an inspection needed the next busin ss d
Accumulative Sewer Tally Parcel # 1S135AA -01400
Tenant Name: Infegumend TI This SWRA 2004 -00046
Site Address: 10215 SW Hall This PLM# 2004 -00050
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 0 0 0 0 .
- 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 0 0 0
- 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 3 6 3 6 •
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- 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 1 6 1 6
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 4 12 4 12
Current Fixture Value 12 divided by 16 = 0.8 Current EDU 1 EDU = $ 2,400
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 12 divided by 16 = 0.8 over (under) $ 1,920.00
Enter EDU Change Here 0.8
Notes:
Signature: 7.l.. 44//4_— ..4 ,- Date: — S' -0/
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher
which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
is \Building \Sewer Tally \SewerTallySheet.xls 11/19/03