Permit ,� CITY OF TIGARD SEWER CONNECTION PERMIT
1411 s COMMUNITY DEVELOPMENT Permit#: SWR2015-00087
T[GARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 07/23/2015
Parcel: 1 S136AD06400
Jurisdiction: Tigard
Site address: 11440 SW PACIFIC HWY
Project: Union 76 Station Subdivision: VILLA RIDGE Lot: 2
Project Description: 1.5 EDU's.
Contractor: Owner: TIGARD BP SERVICE CO INC
11440 SW PACIFIC HWY
TIGARD, OR 97223
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics:, Sewer Connection Fee 07/21/2015 $7,650.00
Sewer Inspection-Commercial 07/21/2015 $45.00
Type of Use: COM
Class of Work: ALT
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: 1.5
Total $7,695.00
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 suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification
Center. Those set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules or direct questions
to OUNC by c ing 503.232. 7 or 0.332.2344. ,� {� ,y
Issued B : Permitted Signature: j, e# 1
Call 503.639.4175 by 7:00 a.m.for the next available inspecti 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.
11 Accumulative Sewer Tally
_ Tenant Name: Union 76 Station SW12# 2015-00087
T I G n R n Site Address: 11440 SW Pacific I Iwy PI.M# 2015-00227
Parcel#: 1S136AD06400
I ixture 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 (I 0 0 0
-Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 (1 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 6 0 0 0 0 0
Garbage Disposal:
-Domestic(to 3/4 HP) 16 0 0 0 0 0
-Commercial(to 5 IIP) 32 0 0 0 0 0
-Industrial(over 5 HP) 42 0 0 0 0 0
Ice Machine/Refrigerator Drain 1 0 0 0 0 (I
Living Unit 16 0 0 0 0 (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:
-Lav/Bar-Non-Food Related 2 0 0 3 6 3 6
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 0 0 0 (I
Swimming Pool Filter 1 0 0 0 0 0
Washer-Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 (I
Water Closet-Toilet 6 0 0 2 12 2 12
Urinal 6 0 0 1 6 1 6
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 6 _ 24 6 24
Current Fixture Value 24 divided by 16= 1.500 Current EDU 1 EDU= $5,100.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 24 divided by 16= 1.500 over (under) $ 7,650.00
Enter EDU Change Here 1.500 *
*Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01. •
Notes: These are existing fixtures in service station that is now being connected to sewer service.
Authorized Name/Signature: Debbie Adamski Date: 7/21/2015
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\Sewer l'allySheet_5100_070115.xlsx