12275 SW TIPPITT PLACE 12275 SW TIPPETT PLACE
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CONNECTION FEE -
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TYPE OF BUILDING �!Ee GATE COiqNEPTEU
SERVICE RATE �`� �►_' _________ INSPECTION FEE ��
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PAID BY DATE
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ASSESSMENT PATO
SIZE OF CONNECTION _._ _.--- —'Y" ��
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City of Tigard
INSPECTION REQUEST
for
INSPECTION TIME ' 2 =et PERMIT NO. :
DATE: P IZ12L DATE ISSUED- Z
OWNERS NAME :
ADDRESS : ����l.-�_ t✓ 1-�-ora'
CONTRACTOR :—
TEST: Air ❑, Water Li , visual 0 , Laboratory! []
_RESULT'. Approveif-01 , Disapproved ❑ Pending 0
SKETCH'.
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UNOT! At. i.;h supplemental test data hsrRtj
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UNIFIED SEWERAGE A _.____`GENCY No. 9594-__- --
WASHINGTON COUNTY DATE - -2Ld-Y-19,-1g'-
figerd
CITY -
y
APPLICATION FOR SI=WER CONNECTION PERMIT
OWNER: — Jatln_A. Loewer-
------ ---------
_—.- 12238 S.W.-Cl
OWNER'S ADDRESS: ydesdale Court -
- STREET 97223
Oregon - — -- ------
Rd Tigard zlr
-..__-_-- CITY
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8 BLOCK ADDITION
Ti pitt Place Subd
BUILDING SITE: LOT
___ - _—_ _—_ --
TAX LOT N0. .--- --- -
TYPE CF OCCUPANCY _ Pesidene9
12275 S.W. Tippitt Place ----
P D D R ESS ._ -- _---
DWELLING UNITS-------- 1 — --- ------__ FIXTURE UNITS _�___�_--------
SURCHARGE I'"= APPLICABLE --
575 _. INSPECTION FEE -- - 25
TOTAL DEPJSITED __ 600 _
PERMIT FEE - - - --
(NEIILL (EXISTING) BUILDING SEWER SYSTEM _ Fannc_ Creek ���
The Applicant agrees to comply with all rules and regulations of the Unified Sewerage Agency.
1.
APPLICANT -- za►Z
SEWER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM.
LINE SIZE __-_-__-.--
INSTALLER -
^FCEIVED BY_ �(A NCYOR�TS AGE T1
COMMENTS: -- Seger connect-tor only - Leron Heights OKKX 150.00
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This Application and permit expires in ninety (g0) days. The amount paid will he forfeited
should expiration occur.