Permit •
A r � - C�ITY OF TIGARD SEWER CONNECTION PERMIT
lA DEVELOPMENT SERVICES PERMIT #: SWR2003 -00015
� ��! 13125 SW Hall Blvd., Tigard, OR 97223 (503) 6 39 -4171 DATE ISSUED: 1/10/03 3
SITE ADDRESS; 11530 SW PACIFIC HWY PARCEL: 1S136DA -00700
SUBDIVISION: ZONING: C -G
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME: HI HAT
USA NO: FIXTURE UNITS: 4
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .3 EDU increase, previous value count was 336, this permit added 4 value units for a new total of
340.
Owner:
FEES
HI HAT INC
11530 SW BARBUR BLVD Description Date Amount
PORTLAND, OR 97219 [SWUSA] Swr Connect 1/10/03 $690.00
[SWUSA] Swr Connect 1/10/03 $0.00
Phone:
• Total $690.00
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
j , i �i ►� Permittee Signature: /�
Issu d by l �_-- -, � - LL 9 I /_�� /i
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the nex • usi e : day
Accumulative Sewer Tally
Tenant Name: Hi -Hat Restaurant This SWR# 2003 -00015
Site Address: 11530 SW Pacific Hwy This PLM# 2003 -00010
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 2 4 2 4
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Dr 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 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 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 21 336 336
Capped EDU Credit 0
TOTALS 0 336 , 0 0 2 4 2 340
Current Fixture Value 340 divided by 16 = 21.3 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 336 divided by 16 = 21.0 Previous EDU
Change 4 divided by 16 = 0.3 over (under) $ 690.00
Enter EDU Change Here 0.3
HISTORY
Notes: Per Sheryl, 21 EDU's PLM# EDU# SWR#
# • EDU# SWR#
PLM /1 EDU# SWR#
Name: , / ' 1, l i 1k • Date:
• nature of • - rson that calculated this tally sheet and date pe med required
-