Permit C ITY OF T I GA RD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2004 -00201
- 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 7/12/2004
SITE ADDRESS; 11507 SW PACIFIC HWY D PARCEL: 1S136AD -04000
SUBDIVISION: VILLA RIDGE ZONING: C -
BLOCK: LOT: 007 JURISDICTION: TIG
TENANT NAME: PREGNANCY RESOURCES
USA NO: FIXTURE UNITS: 8
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .5 EDU increase
Owner: FEES
SMITH, EDITA M
833 NW 170TH DR Description Date Amount
BEAVERTON, OR 97006 [SWUSA] Swr Connectic 7/12/2004 $1,250.00
[SWUSA] Swr Connectic 7/12/2004 $0.00
Phone:
Total $1,250.00
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"
Permit and the Agency will install a lateral. ATTENTION: Oregon law requires you to follow rules adopted by the
Orego - . • = • cation Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952- 001 -0100. You
m- obtain copies o tilese rules or direct questions to OUNC by calling (503) 246 -6699.
ad (4/C/
I sued by: / / 4 / : Permittee Signature: x /
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally Parcel # " ® , q g nati { ' k
Y '� ` i ' ' F 6 `'€ of ;ii W i ° This SWR �^a� -94: �4 k ` 4 k L ,.
„`, s e ° :,,,,, � t> ` £ 4 " � .. This PI-M# 4 a "� k '>ni k i
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 0g " s,. 0 0 0 0
Bath - Tub /Shower 4 ;` ar'- 0
- Jacuzzi/Whirlpool 4 `;`,, , 0 arm 0 11.ftfe; 0 0 0
Car Wash - Each Stall 6 44 5 ` 0 , R.,e2xg 0 *t x`x4 0 0 0
- Drive through 161 0 � 0 =Q 7, t, 0 0 0
Cuspidor/Water Aspirator 1 0 0 Y�s
0 0 0
Dishwasher - Commercial 4 0 0 `!. V. 4 0 0 0
- Domestic 2 0 0 ' :` 0 0 0
Drinking Fountain 1 �; y a m = 0 1,410,4 0 0 0
Eye Wash 1 ' ;` 0 Ns , 0 1 0 0 0
Floor Drain /Sink - 2 inch 2 l,�xs 0 � 0 ? , 0 0 0
- 3 inch 5 0 . ? 0 12:0, 0 0 0
- 4 inch 6 0 � e 0 a 0 0 0
- Car Wash Drr 6 r 0 g., 0 r 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 ; � ' ` 0 3* 0 ' 0 0 0
- Commercial (to 5 HP) 32 0 *' 0 F 0 0 0
- Industrial (over 5 HP) 48 2 0 0_ 0 0 0
Ice Machine/Refrigerator Drain 1 0 1 p .«
Oil Sep (Gas Station) 6 0 g 0 W 0 0 0
Rec. Vehicle Dump station 16 ., 0 ' 0 * 4
Shower - Gang (per head) 1 z 0 0 0 0 0
- Stall 2 4 - ,a - 4,. ° 0 0 i ∎Wz W 0 0 0
Sink - Bar/Lavatory 2 0- 0 zr 0 2 1 2
- Bradley 5 '° 0 0 F� 0 0 0
Commercial 3 0 0 :.� 0 0 0
- Service 3 0 0 , Ik✓4. 0 0 0
i P k e
Swimming Pool Filter I 0 0 0 0 0
Washer - Clothes 6 4 0 0 0 0 0
Water Extractor 6 : 0 { 14 •• 0 ," 0 0 0
Water Closet - Toilet 6 a ` ' 0 0 Am ittgl 6 1 6
4.r
6 �:
Urinal l 0 r 0 ` .., _. 0 0 0
rmwm
Previous EDU Count 0 0
Kites
Capped EDU Credit E ile:„ 0
TOTALS 0 0 0 0 2 8 2 8
Current Fixture Value 8 divided by 16 = 0.5 Current EDU 1 EDU = $ 2,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 8 divided by 16 = 0.5 over (under) $ 1,250.00
Enter E DU Change Here Nara
Notes:
Signature: s Vii -Ai&. " ' Date: ,0
v
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 11/19/03