Permit „e, ..
�, CITY OF TIGARD SEWER CONNECTION PERMIT
� ,� DEVELOPMENT SERVICES
PERMIT #: SWR2003 -00177
- 6. - - ! 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 6/4/03
SITE ADDRESS; 12930 SW SCHOLLS FERRY RD • PARCEL: 1S133AD -02200
SUBDIVISION: ZONING: R -
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME: WESTGATE BAPTIST CHURCH
USA NO: FIXTURE UNITS:
CLASS OF WORK: ADD DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .1 EDU increase, previous fixture values were 16 this permit adds 2 for a new total of 18.
Owner:
FEES
WESTGATE BAPTIST CHURCH Description Date Amount
12930 SW SCHOLLS FERRY RD
TIGARD, OR 97223 [SWUSA] Swr Connect 6/4/03 $230.00
[SWUSA] Swr Connect 6/4/03 $0.00
Phone: Total $230.00
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 given. If not so located, the installer shall purchase a "Tap and Side Sewer” Perm
Issued , ),i; i /' // , 1 Permittee Signature:x
71,,.,, , u or).\
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
I
Ir w Accumulative Sewer Tally
Tenant Name: Westgate Baptist Church - Classroom This SWR# 2003 -00177
Site Address: 12930 SW Scholls Ferry Rd This PLM# 2003 -00241
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 2 2 2 2
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 0 0 0
- 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 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 1 16 16
Capped EDU Credit 0
TOTALS 0 16 0 0 2 2 2 18
Current Fixture Value 18 divided by 16 = 1.1 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 16 divided by 16 = 1.0 Previous EDU
Change 2 divided by 16 = 0.1 over (under) $ 230.00
Enter EDU Change Here 0.1
HISTORY
Notes: PLM# 2002 -00284 EDU# 1 SWR# 2002 -00247
PLM# EDU# SWR#
P ^ EDU# SWR#
(me: i _�:��� ` J$ 1 Date:
�/ /a:
Signature o . erson that calculated this tally sheet and date perfromed is required