Permit ,
�, CITY OF TI GARD SEWER CONNECTION PERMIT
i DEVELOPMENT SERVICES PERMIT #: SWR2003 -00083
'�I I I 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 3 /13/03
SITE ADDRESS; 11571 SW PACIFIC HY PARCEL: 1SI36DB -00201
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SUBDIVISION: FRED MEYER ZONING: C -G
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME: BIG TOWN HERO
USA NO: FIXTURE UNITS: 22
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: 1.4 EDU increase. Previous fixture count was 334.4, this permit capped 11 fixture units and added
33, for a new fixture count of 356.4.
Owner: FEES
WILMINGTON TRUST CO, TRUSTEE
BY FRED MEYER, INC Description Date Amount
3800 SE 22ND AVE [SWUSA] Swr Connect 3/13/03 $3,220.00
PORTLAND, OR 97242 [SWUSA] Swr Connect 3/13/03 $0.00
Phone:
Total $3,220.00
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
Issue y L
h / P e rm ittee S ignature: __ �� ---
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally
Tenant Name: Big Town Hero This SWR# 2003 -00083
Site Address: 11571 SW Pacific Hwy This PLM# 2003 -00075
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 3 6 3 6
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drr 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 1 1 1 1
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 1 2 4 8 3 6
- Bradley 5 0 0 0 0 0
- Commercial 3 0 1 3 2 6 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 1 6 2 12 1 6
Urinal 6 0 0 0 0 0
Previous EDU Count 20.9 334.4 334.4
Capped EDU Credit 0
TOTALS 0 334.4 3 11 12 33 9 356.4
Current Fixture Value 356.4 divided by 16 = 22.3 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 334.4 divided by 16 = 20.9 Previous EDU
Change 22 divided by 16 = 1.4 over (under) $ 3,220.00
Enter EDU Change Here 1.4
HISTORY
Notes: PLM# 2001 -00227 EDU# 20.9 SWR# 2001 -00182
PLM# 2000 -00460 EDU# 20.7 SWR# 2001 -00132
L-M# 3/21/01 EDU# 12.6 SWR#
.,
me: , � , - - (�VA' 4 Date: '/�.2-�40-
Signature person that calculated this tally sheet and date perfromed is required