Permit a c • ,
CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT PERMIT #: SWR2009 -00001
TIGARD DATE ISSUED: 1/7/2009
13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 PARCEL: 2S102D6 - 00500
SITE ADDRESS: 08815 SW O'MARA ST ZONING: CBD
SUBDIVISION: FANNO CREEK PARK LOT: JURISDICTION: TIG
PROJECT: TIGARD SENIOR CENTER GARDEN RM
Project Description: .2 EDU increase
TENANT NAME: TIGARD SENIOR CENTER
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:
CITY OF TIGARD FEES
13125 SW HALL Description Date Amount
TIGARD, OR 97223
Total l �
Phone: 503- 639 -4171
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.
Issue; by: , 'LI �L Permittee Sig ture:
Call 503.639.4175 by 7:00 a.m. for an inspection th usiness 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.
t Accumulative Sewer Tally Parcel # •2S102DB -00500
Tenant Name: Tigard Senior Center - Garden Room This SWR# 2009 -00001
Site Address: 8815 SW O'Mara St This PLM# 2009 -00004
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
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
- 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 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 1 3 1 3
- 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 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS _ 0 0 0 0 1 _ 3 1 3
Current Fixture Value 3 divided by 16 = 0.2 Current EDU 1 EDU = $ 3,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 3 divided by 16 = 0.2 over (under) S 620.00
Enter EDU Change Here 0.2
Notes:
Authorized Name /Signature: Debbie Adamski Date: 1/7/2009
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 \Sewer Tally \SewerTallySheet- 3100.xls 06/19/08