Permit CITY OF TIGARD
SEWER CONNECTION PERMIT
awoot i DEVELOPMENT SERVICES PERMIT #: SWR2003 -00327
..� II 13125 SW Hall Blvd., Tigard, OR 9722 (503) 639 -4171 DATE ISSUED: 8/15/03
SITE ADDRESS; 13165 SW PACIFIC HY PARCEL: 2S102CB -00303
W
SUBDIVISION: NORTH TIGARDVILLE ADDITION ZONING: C - G
BLOCK: LOT: 033 JURISDICTION: TIG
TENANT NAME: LONG JOHN SILVERS /AW
USA NO: FIXTURE UNITS: 4
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .1 EDU increase: previous =2.8 EDUs for a total of 44.8 fixture values. Addition of 4 fixture values,
for a new total of 46.8 fixture values =2.9 current EDUs.
Owner:
FEES
POORMAN, JOHN AND MARTHA
14243 NW EVERGREEN ST Description Date Amount
PORTLAND, OR 97229 [SWUSA] Swr Connect 8/15/03 $0.00
[SWUSA] Swr Connect 8/15/03 $240.00
Phone: Total $240.00
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
Issued by: �I . Permittee Signature:
• ' kg
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next b. i' ess day
Accumulative Sewer Tally
Tena:.4. me: Long John Silver /A &W This SWRh 2003 -00327
Site Address: 13165 SW Pacific Ave. This PLM# 2003 -00436
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 1 2
-3inch 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 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 2:8 44.8 44.8
Capped EDU Credit 0
TOTALS 0 44.8 0 0 1 2 1 46.8
Current Fixture Value 46.8 divided by 16 = 2.9 Current EDU 1 EDU = $ 2,400
Previous Fixture Value 44.8 divided by 16 = 2.8 Previous EDU
Change 2 divided by 16 = 0.1 over (under) $ 240.00
Enter EDU Change Here 0.1
HISTORY
Previous: Ami/Water dept. PLM# EDU# SWR#
PLM #• EDU# SWR#
PLM# EDU# SWR#
Name: £ Zeazllf ,1 ,rte Date: (f -/ S -D3
Signature of person that calculated this tally sheet and date perfromed is required