Permit 4 C ITY OF TIGARD SEWER CONNECTION PERMIT
A!- 4 DEVELOPMENT SERVICES PERMIT #: SWR2003 -00404
44. 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 12/26/03
SITE ADDRESS; 06650 SW REDWOOD LN 150 PARCEL: 2S112DA -01400
SUBDIVISION: PP1996 - 048 ZONING: I -
BLOCK: LOT: 002 JURISDICTION: TIG
TENANT NAME: THOM FAGLIE LASER CENTER
USA NO: FIXTURE UNITS: 7
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: 1.1 EDU increase. Addition of 7 fixtures for a total fixture value of 18 fixture values.
Owner:
FEES
PACIFIC REALTY ASSOCIATES
15350 SW SEQUOIA PKWY #300 -WMI Description Date Amount
PORTLAND, OR 97224 [SWUSA] Swr Connect 12/26/03 $2,640.00
[SWUSA] Swr Connect 12/26/03 $0.00
Phone: Total $2,640:00
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: Permittee Signature: t ''
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next b t ess day
Accumulative Sewer Tally Parcel # 2S112DA -01400
Tenant Name: Thom Faglie Laser Center This SWR112003 -00404
Site Address: 06650 SW Redwood Ln. Ste. #150 This PLM# 2003 -00624
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 1 2 1 2
- 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 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 5. 10 5 10
- 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 1. 6 1 6
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 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 7 18 7 18
Current Fixture Value 18 divided by 16 = 1.1 Current EDU 1 EDU = $ 2,400
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 18 divided by 16 = 1.1 over (under) $ 2,640.00
Enter EDU Change Here 1.1
Notes:
Name: I/f / i „ If �7 _ L Date: ,(V / /U ��
Building Division
IT Note: The property owner shall retain this record for sewer credit purposes. In the event of a credit, this
document stamped "ORIGINAL" shall serve as a credit voucher and must be submitted to the City of
igard Building Division to redeem credit towards future system development charges.