Permit 1111 a CITY OF TIGARD SEWER CONNECTION PERMIT
° COMMUNITY DEVELOPMENT PERMIT #: SWR2008 - 00129
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 8/27/2008
PARCEL: 1 S136AD -04000
SITE ADDRESS: 11509 SW PACIFIC HWY ZONING: C -
SUBDIVISION: PACIFIC TERRACE LOT: 007 JURISDICTION: TIG
PROJECT: VILLELA THERAPUTIC CENTER
Project Description: .4 EDU increase.
TENANT NAME: VILLELA THERAPUTIC CENTER
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0.4
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner:
SMITH, EDITA M FEES
833 NW 170TH DR Description Date Amount
BEAVERTON, OR 97006
CITY OF TIGARD 8/27/2008 $1,240.00
Phone: Total $1,240
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 by: / a , % ` ` �� Permittee Signature: �
Call 503.639.4175 by 7:00 a.m. for an inspection that business 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.
iy Accumulative Sewer Tally Parcel # 1S136AD - 04000
Tenant Name: VILLELA THERAPUTIC CENTER This SWR# SWR2008 - 00129
' Site Address: 11509 SW PACIFIC HWY This PLM# PLM2008 - 00355
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
- 4inch 6 0 0 0 0 0
-Car Wash Dm 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) 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 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 1 6 1 6
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 6 1 6
Current Fixture Value 6 divided by 16 = 0.4 Current EDU 1 EDU = $ 3,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 6 divided by 16 = 0.4 over (under) S 1,240.00
Enter EDU Change Here • 0.4
Notes:
Authorized Name /Signature: BRANDEN TAGGART Date: 8/27/2008
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 \Sewer Tally \ SewerTallySheet-3100.xls 06/19/08