Permit A CITY OF TIGARD SEWER CONNECTION PERMIT
1psi4 DEVELOPMENT SERVICES PERMIT #: SWR2002-00253
^� J " 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 9/30/02
SITE ADDRESS; 13727 SW PACIFIC HY 100 PARCEL: 2S103DD -00400
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SUBDIVISION: ZONING:
BLOCK: LOT: JURISDICTION:
TENANT NAME: DR. FEELGOOD'S
USA NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: 2.5 EDU increase. Previous fixture units were 60.8, this permit added 40 units for a new total of
100.8.
Owner:
FEES
WILSON'S TIGARD RETAIL CENTER Description Date Amount
BY BOMCC ESCROW ADMINISTRATION
TX 1 -2495 [SWUSA] Swr Connect 9/27/02 $5,750.00
DALLAS, TX 75201
Phone: • Total $5,750.00
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: #62. Permittee Signature: 61/ j r�7■9s`
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally
Tenant Name: Dr. l eigood's This SWR# 2002 -00253
Site Address: 1'3727 SW Pacific Hwy #150 This PLM# 2002 -00336
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
-3inch 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 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 3 6 3 6
- 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 3 18 3 18
Urinal 6 0 - 0 2 12 2 12
Previous EDU Count 3.8 60.8 60.8
Capped EDU Credit 0
TOTALS 0 60.8 0 0 10 40 10 100.8
Current Fixture Value 100.8 divided by 16 = 6.3 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 60.8 divided by 16 = 3.8 Previous EDU
Change 40 divided by 16 = 2.5 over (under) $ 5,750.00
Enter EDU Change Here 2.5
HISTORY
Notes: 3.8 EDU's per PLM# EDU# SWR#
per Jaime in acct. PLM# EDU# SWR#
p , -- EDU# WR#
Na e: � i . ,,/ i�� ._.. �� /ii.,� /� Date: 9
14
nature of , erson that calculate. this tally sheet and date perfromed Is required