Permit •
Ilh CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT PERMIT #: SWR2008 - 00013
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 2/20/2008
PARCEL: 1 S 126 DC -04800
SITE ADDRESS: 09495 SW LOCUST ST A ZONING: C -P
SUBDIVISION: LEHMANN ACRE TRACT LOT: 004 JURISDICTION: TIG
PROJECT: KLEIN DERMATOLOGY
Project Description: .2 EDU increase.
TENANT NAME: KLEIN DERMATOLOGY
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0.2
TYPE OF USE: CMS NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner:
BAKER, JAMES + FEES
9495 SW LOCUST ST. #G Description Date Amount
BAKER, DIANE R
TIGARD, OR 97223 [SWUSA] Sewer Connection Fee 2/20/2008 $560.00
Phone: NA
Total $560.00
Contractor:
Contact #: REQUIRED ITEMS AND REPORTS
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 b.: 1 , �4 1 , / Permittee Signature: i _____ �� /
Call 503.639.4175 by 7:00 a.m. for an inspection that business day. /1,- /-
This permit card shall be kept in a conspicuous place on the job site until completion of the pr. ;.
Approved plans are required on the job site at the time of each inspection.
Accumulative Sewer Tally Parcel # 1S126DC - 04800 ;
Tenant Name:~lKlcin Dermatology This SWR# 2008 -00013
Site Address: 9495 SW Locust St Suite A This PLM# 2008 - 00059
_ Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #5 values
Baptistry /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
- 3inch 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 I -IP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 1-IP) 42 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 0 0 0
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 3 0 0 1 3 1 3
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 0 0 0
Urinal 6 0 0 0 0 0
Previous [DU Count 0 0
Capped EDU Credit 0
I'O "I'ALS 0 0 0 0 1 _ 3 1 3
Current Fixture Value 3 divided by 16 = 0.2 Current EDU 1 EDU = 5 2,800
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 3 divided by 16 = 0.2 over (under) S 560.00
Enter EDU Change Here 0.2
N otes:
Authorized Name /Signature: Debbie Adamsl Date: 2/20/2008
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.
I' \ Building \ Forms \Sewerl'allyShcct.xls 112/02/07