Permit CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit#: SWR2015-00184
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 12/23/2015
Parcel: 1 S135BC00202
Jurisdiction: TIGARD
Site address: 10763 SW GREENBURG RD 100
Project: Acadia Healthcare Subdivision: OAKBURG Lot: 27
Project Description: 2.19 EDU Increase
Contractor: Owner: BELANICH, ROGER M
22020 17TH AVE SE#200
BOTHELL,WA 98021
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 12/23/2015 $11,169.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: 2.19
Total $11,169.00
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 wit i 180 days of issuance, or if
work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules ado d�by e Oregon Utility Notification
Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may 4date.
PY f the rules or direct questions
to OUNC by calling 503.2-32.1987 or 1.800.332.2344.
Issued By: �,� Permittee Signature:
Call 503.639.4175 by 7:00 a.m.for the next available inspec o
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.
CCAccumulative Sewer Tallv
Tcnant Name: Acadia I-Icalthcare SWIZ# 2015-00184
SiteAddress: 10763S\C/GrecnburgRd,Stc100 1'I.t11 # 2015-00427
Parcel#: 1S135BC00202
Mixture Value Previous PrCViOLII Credits Capped Fixture Fixture New New
# value count cap ped#s value Connt added# added value total#s total values
lia ptiscry/Dont 4 0 0 0 0 0
Rath: -Tub/Shower 4 0 0 0 0 0
-Iacuzri/\VlIirl oul 4 0 0 0 0 0
Car Wash: -1=?ach Stall 6 0 0 0 0 0
Drive throe gh 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
I:vc
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 1-11') 16 0 0 0 0 0
Commercial (to 5 1-1 P) 32 0 0 0 0 0
Industrial(over 5 1-1 P) 42 0 0 0 0 0
[cc Alachinc/Rcfri gcrator Drain 1 0 0 1 1 1 1
Living Unit 16 0 0 0 0 0
Oil Sep(Gas Station) 6 0 0 0 0 0
RCC.Vehicle Dump station 16 0 0 0 0 0
Shower: -Gan (per head) 1 0 0 0 1 0 1 0
Stall 2 0 0 0 0 0
Sink:
Lav/Bar-Nun-Food Related 2 0 3 6 14 28 11 22
BradleN, 5 0 0 0 0 0
Cum/Sery/Util-Food Related 3 0 0 0 0 0
Swimming Pool I iltcr 1 0 0 0 0 0
Washer-Clothes 6 0 0 0 0 0
Water I_.stractur 6 0 0 0 0 0
Water Closet-Toilet 6 0 4 24 6 36 2 12
Urinal 6 0 0 0 0 0
PYCV1UnS FDU Count 0 0
Capped 13DU Credit 0
IOTA LS 0 0 7 30 21 65 14 35
Current Mixture Value 35 divided by 16= 2.188 Current FDU 1 EDU= $5,100.00
Previous fixture Value 0 divided by 16= 0.000 Previous FDU
Change 35 divided by 16= 2.188 over (under) S 1 1,169.00
Enter EDU Change Here 2.190
'Round F.DUs to the nearest I/100th: a count ending in.005 shall be rounded up to.0 1,and a count ending in.014 or less shall be rounded down to.01.
Notes:
Authorized Namc/Signature: Dianna Howse Date: 12/22/2015
Building Division
Note: The property owner shall retain the ORIGINAL,sewer tall-record. I f credits dist,this document will scree as a voucher which nntst be
subnpittcd to the City of Tigard Building Division to redeem credits towards future system development charges.
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