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13485 SW BARNUM DRIVE
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ADDRESS 1 �5(• ,d, �* , �i,,.�.1�, PERMIT N0. ,i(rX
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PERMIT CHARGE none
OWNER CONNE=CTION FEE A3-�5
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PAID BY �,r--_—
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TYPE OF BUILDINGDATE CONNECTED
SERV I",t RPfE _ �,��Qxe _ INSPECTION FEE
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CONTRACTOR ( �(�,�, _ PAID BY DATE
SIZE OF CO"ECTION ASSESSMENT PA'D
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City of Tigard
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INPECTION IREO U E$T
for
IINSPECTION TIME PERMIT NO. :
DA's: . DATE ISSUED.
I OWNERS NAME :
ADDRESS :
I CONTRACTOR
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TEST: Air O, Water p , Visiall�, Laboratory ❑
IRESULT: Approved 08 , Disappro,ed 0 Pending [
SKETCH:
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INSPECTOR DATE
ENO?E : Attach supplemental test data herst'01
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UNIFIED SEWERAGE AGEN%Y NO. 5062 __ _
WASHING TON COUNTY DATE 3-21-75
CI I Y OF -- _ Ti,jard
APPLICATION FOR SEWER CONNECTION PERMIT
OWNLR: Aioy_n Schultz
OWNER'S ADDRESS: _ 10485-5-,L.—Lade ada1e--PI-ai_,3
STREET
_._ ._ Tigard Oregon___ _
CITY STATE ZIP
BUILDING SITE: LOT 1 BLOCK - ADDITION _Barnum -Perk Subo,,
TAX LOT NO. . _ TYPE OF OCCUPANCY
ADDRESS __ 13485 S,L!. Barnum Drive
DWELLING UNITS------.--1 _- - FIXTURE UNITS
SURCHARGE IF APPLICABLE ----
PERMIT
PPLICABLE ____PERMIT FEE _525 .4SPECTION FEE 25 -__ TOTAL DEPOSITED _—
(NEW) (EXISTING) BUILDING SEWER SYSTEM Fanria—Cre
The Applicant agrees to comply with all rules and regulations of the Unified Sewerage Agency.
APPLICANT
SEWER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM.
LINE SIZE __ 411 _ INSTALLEP
RECEIVED B Y
✓IAGENCY OA
COMMENTS: __ County_to issue_ the building permit. . . .
This Application and permit expires in ninety (90) days. The amount paid will be forfeited
should expiration occur.
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