Permit CITY T I GA R D SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2005 -00039
r11i 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 2/14/2005
SITE ADDRESS; 10575 SW CASCADE AVE 130 PARCEL: 1S135BB -00501
SUBDIVISION: ZONING: I -P
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME: HEMCON
USA NO: FIXTURE UNITS: 1
CLASS OF WORK: ADD DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .1 EDU increase
Owner: FEES
AMB PROPERTY L P
BY TRAMELL CROW NW INC Description Date Amount
8930 SW GEMINI DR [SWUSA] Swr Connectic 2/14/2005 $250.00
BEAVERTON, OR 97008 [SWUSA] Swr Connectic 2/14/2005 $0.00
Phone: Total $250.00
Contractor:
REQUIRED ITEMS AND REPORTS
Phone:
Reg #:
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 obtai• ::'es of these rules or direct questions to OUNC by calling (503) 246 -6699.
Issue. by: , Permittee Signature: „ �
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the t busin: • .y
,
' " Accumulative Sewer Tally Parcel # 1S135BB -00501
Tenant Name: Hemcon - This SWR# 2005 -00039
Site Address: 10575 SW Cascade Ave Ste 130 This PLM# 2005 -00057
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 1 2 1 2
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 1 2 0 -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) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 1 1 1 1
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 0 0
Capped EDU Credit 0
TOTALS 0 0 1 2 2 3 1 1
Current Fixture Value 1 divided by 16 = 0.1 Current EDU 1 EDU = $ 2,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 1 divided by 16 = 0.1 over (under) $ 250.00
Enter EDU Change Here 0.1
Notes:
Sign ture: . / _' . u 1 Date: / 4, 4S
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.xls 7/1/04