Permit CITY OF TIGARD SEWER CONNECTION PERMIT
• COMMUNITY DEVELOPMENT Permit #: SWR2012 -00178
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 08/14/2012
Parcel: 2S110DCO2300
Jurisdiction: Tigard
Site address: 11515 SW DURHAM RD E -9
Project: Naturo Medicine Center Subdivision: 1998 -128 PARTITION PLAT Lot: 1
Project Description: .880 EDU increase
Contractor: Owner: HIP WILLOWBROOK LLC
BY HARSCH INVESTMENT CORP
PO BOX 2708
PORTLAND, OR 97208
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 08/14/2012 $4,105.20
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .880
Total $4,105.20
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable
law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if
work is s • - i .ed for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification
Center Those ru - are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obtain a copy of the rules or direct questions
to OU C by calling 503. • 32.1 • : or 1.800.332.2344.
Iss d By:
■ j 440 Permittee Signature:
Call 503.639.4175 by 7:00 a.m. for the next available Inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project. -
Approved plans are required on the job site at the time of each inspection.
Accumulative Sewer Tally
4
p . Tenant Name: Naturo Medicine Center SWR # 2012 -00178
T G n It D Site Address: 11515 SW Durham Rd #E -9 PLM # 2012 -230
Parcel #: 2S11000O2300
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped #s value count added # added value total #s total 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 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 I -IP) 42 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:
- Lav /Bar - Non -Food Related 2 0 0 2 4 2 4
- Bradley 5 0 0 0 0 0
- Com /Serv/Util - Food Related 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 5 14 5 14
Current Fixture Value 14 divided by 16 = 0.875 Current EDU 1 EDU = $4,665.00
Previous Fixture Value 0 divided by 16 = 0.000 Previous EDU
Change 14 divided by 16 = 0.875 over (under) $ 4,105.20
Enter EDU Change Here 0.880
Notes: Per Becky, CWS, for the Colon Hydro Therapy devices since they utilize a 2" drain, calculate them as a 2" floor drain.
Authorized Name /Signature: Debbie Adamski Date: 8/13/2012
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
I: \Building \Sewer Tally \SewerTallySheet -4665. xls 07/01/12