Permit •
CI TY OF TI GARD SEWER CONNECTION PERMIT
ilk DEVELOPMENT SERVICES PERMIT #: SWR2005 -00030
° ' ' � 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 2/7/2005
SITE ADDRESS; 13500 SW PACIFIC HWY 50 ONE HOUR PARCEL: 2S102CC -00500
SUBDIVISION: PHOTO ZONING: C -
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME:
USA NO: FIXTURE UNITS: 12
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .4 EDU increase.
Owner: FEES
13500 PACIFIC CORP
BY CAP ADVISORS Description Date Amount
38345 W TEN MILE RD, STE 170 [SWUSA] SwrConnectic 2/7/2005 $1,000.00
FARMINGTON HILLS, MI 48335 [SWUSA] SwrConnectic 2/7/2005 $0.00
Phone:
Total $1,000.00
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
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.
Issued by: . Permittee Signature: )
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally Pa rcel # � �t 1 r7t ,
�
Ternatttme ,.�N S tyle i ; ! ' This SW RA ��� z
e' to lkddres; � 1a 76,,0 ...0 0,:c:Hwy. P, 5O This PLM# Q€ a Q 4_ .:
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 r 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
Jacuzzi /Whirlpool 4 0 , ,, „' ,, 0 4'-:-',,:''":" 0 0 0
Car Wash - Each Stall 6 0 b 0 0 0 0
Drive through 16 0 0` g 0 0 0
Cuspidor /Water Aspirator 1 0 0 0 0 0
Dishwasher - Commercial 4 , >, y 0 .. •Wr 4 ` 0 l 0 0 0
- Domestic 2 0 t x ? ; T , > 0 0 0 0
Drinking Fountain 1 0 0
Eye Wash 1 0 � v , '; 0 0 0 0
Floor Drain /Sink 2 inch 2 A *
4 0 A ; / ,. r 0 .` X, 0 0 0
- 3 inch 5 .> 0 �,r 0 r� 0 0 0
4 inch 6y 0 Xd�'i 0 i x ,� � 0 0 0
Car Wash Drn 6 4' � 0 Wk ' z ''
Garbage Disposal
0 0 0
Domestic (to 3/4 HP) 16 il 0'
Commercial (to 5 HP) 32 a 1, 0 0 , 0 0 0
Industrial (over 5 HP) 42 0 , kg O >' 1 0 0 0
Ice Machine /Refrigerator Drain 1 0 `tit: 0 I, 0 0 0
Oil Sep (Gas Station) 6 i 0 , 0 : ; 0 0 0
Rec. Vehicle Dump station 16 i ` 3 0 �4' 0 g 0 0 0
Shower Gan er head 1 0-1,44y: xy,
ri1111* Stall 2 01 0 0 0 0
Sink Bar /Lavatory 2� 0 0 �� 0 0 0
- Bradley 5 0 0 � ` tk ` 0 0 0
tx y . 'kx
- Commercial 3 z '� s 0 `4 x :!' 0 1 4 , �, 6 2 6
Service 3 � 0 .: 0 0 0 0
Swimming Pool Filter 1 � � 0;" 0 � 0 0 0
Washer - Clothes 6 0 k? 0 0 0 0
Water Extractor 6 0 v' 0$fi >: 0 0 0
Water Closet - Toilet 6 4� ✓ , 0 �,' 0 0 0 0
Urinal 6 s V - . 0 �, ,:': 0 y. 0 0 0
.._...____._......___..
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 2 6 2 6
Current Fixture Value 6 divided by 16 = 0.4 Current EDU 1 EDU = $ 2,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 6 divided by 16 = 0.4 over (under) $ 1,000.00
Enter EDU Change Here ; X1_,,.
Notes:
Signature: i�.�Ll - � /c.. - 4,i'. - Date: - / 7 - 6 - : r >
Building Div
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.xls 7/1/04