Permit CITY TIGARD SEWER CONNECTION PERMIT
PERMIT #: SWR2005 -00189
i4, DEVELOPMENT SERVICES
All 131 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 6/16/2005
PARCEL: 2S10100-01202
SITE ADDRESS: 07930 SW HUNZIKER RD ZONING: I -L
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: EDU increase.
F3
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0 3
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
COE MANUFACTURING COMPANY
PO BOX 520 Description Date Amount
PAINESVILLE, OH 44077 [SWUSA] Sewer Connection Fee 6/16/2005 $750.00
Total $750.00
Phone:
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 o -; '0-3 -2344.
Permittee Signature: Issued by: , ` , . 1 _,-, 9 / / ' -_
/ /
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that b • - . s ay.
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.
Accumulative Sewer Tall Parcel #' •®a k 6 k
T ..1 :4 41P0,r tcose = , This SWR# ft. 1kt,1 '° r ; ^ s
;Ste.Addess93'1ntlkr < „ . This PLM# (9 `b 6 F ;, ,
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
y te a'. x •
Baptisery/Font 4 0 0 • r 0 0 0
Bath - Tub /Shower 4 ▪ 0 a , 0 , , , 0 0 0
- Jacuzzi /Whirlpool 4 0 0 , , „4 0 0 0
Car Wash - Each Stall 6 0 0 0 0 0
9
- Drive through 16 0 r 3. 0
Tx.�., 44 0 0 0
Cuspidor/Water Aspirator 1
Dishwasher - Commercial 4 h ` ., 0 "As .,Y 4, t 0 k 0 a 0
- Domestic 2 0 =� .�. 1 ., °, � , 0 i 2 1 2
Drinking Fountain 1 ▪ 0v 0 0 0
• Eye Wash 1 0 Wax � , N 0
0
Floor Drain /Sink - 2 inch 2 0 < ; 0 .� 1 , - 0 0 0
- a
. '�*�i Rz Vii;
- 3 inch 5 x.• 0 y i �• ;<,. z ,- 0 0 0
4 inch 6 g 0 ,- 0 " 0 0 0
- Car Wash Dm M% 0 z �r.,.,, j, ,, 0 ', F% � ., 0 0 0
Garbage Disposal .
- Domestic (to 3/4 HP) 16 m : Vle 0tn `° 0 „ 0 0 0
- Commercial (to 5 HP) 32 ` 4 ' 0 'AS, 0 4t# . 4Y..-it 0 0 0
- Industrial (over 5 HP) 42 : &� 0 � 2 0 , ` A 0 0 0 •
Ice Machine /Refrigerator Drain 1 �, 0 t 0 :,. 0 0 0
Oil Sep (Gas Station) 6 ;. , F , 0 4 a,::, : 0 ,t1: 0 0 0
Rec. Vehicle Dump station 16 ;* , 0 ,, 4 ,� 0 k 0 0 0
* of
Shower - Gang (per head) 1 0 �,� > ` 0 , 0 0 0
Stall 2
w 0 �° 0 0 0
,' kj . 1. 0 Olin k>
Sink - Bar /Lavatory 2 0 0 �.,r,,; 0 0 0
- Bradley 5 �n 0 5-''''1/4, g . : 0 . -
- Commercial 3 0 0 0
�, 0 0 ' z 3 1 3
- Service 3 tk? 0 0 0 0 0
Swimming Pool Filter 1 � 0 f 0 0 0 0
Washer - Clothes 6 y' 0 � x 0
' 0 0 0
Water Extractor 6 1 0 '. 0 x` a eft, 0 0 0
Water Closet - Toilet 6 .�;` , 4 0 Kip >� 0 3 .� 0 0 0
Urinal 6 i ., �'�`he 4 0 . I 0 : : 4 0 0 0
k
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 _ 0 0 0 2 5 2 5
Current Fixture Value 5 divided by 16 = 0.3 Current EDU 1 EDU = $ 2,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 5 divided by 16 = 0.3 over (under) $ 750.00
Enter EDU Change Here 1i4
Notes:
Signature: 744 t c _ - Date: ,!> eil c
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 7/1/04