Permit 4 CITY TIGARD SEWER CONNECTION PERMIT
ll DEVELOPMENT SERVICES PERMIT #: SWR2003 -00187
"�� 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 - DATE ISSUED: 6/30/03
SITE ADDRESS; 10865 SW WALNUT ST PARCEL: 2S103AA -00101
SUBDIVISION: ZONING: R - 4.5
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME: FOWLER MIDDLE SCHOOL
USA NO: FIXTURE UNITS: 2
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .1 EDU increase. Previous fixture values were 593, this permit adds 2 fixture values for a new total
of 595.
Owner:
FEES
SCHOOL DISTRICT NO 23 J
13137 SW PACIFIC HWY Description Date Amount
TIGARD, OR 97223 [SWUSA] Swr Connect 6/30/03 $230.00
[SWUSA] Swr Connect 6/30/03 $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 distance given. If not so located, the installer shall purchase a "Tap and Side Sewer" Perm
Issue • . 4:1 , - i,!i %� Permittee Signature:
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally
Tenant Name: Fowler. Middle School This SWR# 2003 -00187
Site Address: 10865 SW Walnut St - This PLM# 2003 -00155
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 Dr 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 1 2 1 2
- 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 37.1 593.6 593.6
Capped EDU Credit 0
TOTALS 0 593.6 0 0 1 2 1 595.6
Current Fixture Value 595.6 divided by 16 = 37.2 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 593.6 divided by 16 = 37.1 Previous EDU
l Change 2 divided by 16 = 0.1 over (under) $ 230.00
Enter EDU Change Here 0.1
HISTORY
Notes: 5/15/01, per acct, 37 DU'5 PLM# 2001 -00197 EDU# 37.1 SWR# N/A
PLM# EDU# SWR#
M# EDU# SWR#
me: - . _ � I ` ■ : Date: 61 /0.3
Signature of perso that calculated this tally sheet and date perfro d is required