Permit C ITY OF TIGARD SEWER CONNECTION PERMIT
PERMIT #: SWR2002 -00345
4 � DEVELOPMENT SERVICES DATE ISSUED: 12/30/02
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS; 12442 S W SCHOLLS FERRY RD * * ** PARCEL: 1S134BC -00401
SUBDIVISION: ZONING: C -N
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME: PROVIDENCE HEALTH SYSTEMS
USA NO: FIXTURE UNITS: 12
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .7 EDU increase. Previous fixture units were 198, this permit added 12 fixture units for a new total
of 210 fixture units.
Owner: FEES
SISTERS OF PROVIDENCE IN OR
BY STEVE FOSTER Description Date Amount
PO BOX 13993 [SWUSA] Swr Connect 12/30/02 $1,610.00
PORTLAND, OR 97213 [SWUSA] Swr Connect 12/30/02 $0.00
Phone:
Total $1,610.00
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
Issue y: • I ,s r , 4 ' d, ! 1 Permittee Signature: �/
�JA
Call (503) 639 . 175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally
Tenant Name: ',;caters of Providence This SWR# 2002 -00345
Site Address: 12442 SW Scholls Ferry Rd This PLM# 2002 -00502
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 0 0 0
- 3 inch 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 1 6 1 6
Urinal 6 0 0 0 0 0
Previous EDU Count 12.375 198 198
Capped EDU Credit 0
TOTALS 0 198 0 0 4 12 4 210
Current Fixture Value 210 divided by 16 = 13.1 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 198 divided by 16 = 12.4 Previous EDU
Change 12 divided by 16 = 0.8 over (under) $ 1,610.00
Enter EDU Change Here 0.7 .
HISTORY
Notes: PLM# 2000 -00010 EDU# 12.38 SWR# 2000 -00009
PI Acct EDU# 10 SWR# 3/26/96
PLM# EDU# SWR#
Name Date: /4D � --
ignature of person that calculated this tally sheet and date perfrome Is required