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Permit 1+• 4 - . CITY OF TIGARD SEWER CONNECTION PERMIT 11 DEVELOPMENT- SERVICES PERMIT #: SWR2003 -00371 - 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 1/7/04 SITE ADDRESS; 11565-SW PACIFIC HWY PARCEL: 2S 102CC -00600 SUBDIVISION: 13345 ZONING: C - BLOCK: LOT: JURISDICTION: TIG TENANT NAME: QUICKLUBE USA NO: FIXTURE UNITS: 39 CLASS OF WORK: NEW DWELLING UNITS: TYPE OF USE: COM NO. OF BUILDINGS: 1 INSTALL TYPE: LTPSWR IMPERV SURFACE: Remarks: 2.4 EDU current count. (not previously on sewer) 2.4 EDU =39 fixture values. Owner: FEES DDHK VENTURES, LLC 12604 SW 60TH CT Description Date Amount PORTLAND, OR 97219 [SWUSA] Swr Connect 1/7/04 $5,760.00 [SWUSA] Swr Connect 1/7/04 $0.00 Phone: 503- 977 -0578 [SWINSP] Swr Inspect 1/7/04 $45.00 [SWINSP] Swr Inspect 1/7/04 $0.00 Contractor: Total $5,805.00 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: PermitteeSignature• _/ _ L Call (503) 6394175 by 7:00 P.M. for an inspection needed the next business day . • as- .- P Acc mulativ Sewer Tally Tenant Name: Quicklube This SWRii 2003 -00371 Site Address: 565,.SW Pacific Hwy. This PLM# 2003 -00483 /35 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 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 1 1 1 1 Oil Sep (Gas Station) 6 0 0 1 6 1 6 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 2 4 2 4 - Bradley 5 0 0 0 0 0 - Commercial 3 0 0 4 12 4 12 - 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 2 12 2 12 Urinal 6 0 0 0 0 0 Previous EDU Count 0 0 0 Capped EDU Credit 0 TOTALS 0 0 0 0 12 39 12 39 Current Fixture Value 39 divided by 16 = 2.4 Current EDU 1 EDU = $ 2,400 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change 39 divided by 16 = 2.4 over (under) $ 5,760.00 Enter EDU Change Here 2.4 HISTORY Previous: New building. PLM# EDU# SWR# Fixture count provided by PLM# EDU# SWR# John Williams /plumbing. PLM# EDU# SWR# i Name:: ;G. , /i:! , .� ,// Date: —oZ6 Signature of person that calculated this tally sheet and date perfromed is required _ Accumulative Sewer Tally Tenant Name: 0-4,4 i c u/ h This SWR# a 00 3 -(Z? 3-7 Address: 13 SG S Sw P : F.,, 4 This PLM #: 2 oo 3- O n q (L3 Fixture Value Previous Previous Credits Capped Fixtures Fixtures New total New # Value Capped off value added # added #s total Count off #s count value , values Baptistry/Font 4 Bath - Tub /Shower 4 - Jacuzzi/Whirlpool 4 Car Wash - Each Stall 6 - Drive Through 16 Cuspidor/Water Aspirator 1 Dishwasher - Commercial _ 4 - Domestic 2 • • Drinking Fountain 1 Eye Wash 1 Floor Drain /sink - 2 inch 2 - 3 inch 5 - 4 inch 6 - Car Wash Drn 6 Garbage Disposal 16 - Domestic (to 3/4 HP) - Commercial (to 5 HP) 32 - Industrial (over 5 HP) s 42 / Ice Machine /Refrigerator Drains 1 Oil Sep (Gas Station) 6 Rec. Vehicle Dump Station 16 , Shower - Gang (Per Head) 1 - Stall 2 Sink - Bar /Lavatory 2 2 - Bradley 5 - Commercial 3 L I - Service 3 Swimming Pool Filter 1 Washer - Clothes 6 , Water Extractor 6 • Water Closet - Toilet 6 2 Urinal 6 TOTALS , Total fixture values: divided by 16 = EDU HISTORY PLM# ' EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# • iAdstslswrtaly.doc