8000 SW PFAFFLE STREET 8000 SW PFAFFLE STREET
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City of Tigard
INSPECTION REO U E ST
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INSPECTION TIME : L PERMIT NO. .'
I DATE : .'�;'_1_" – DATE ISSUED
OWNERS NAME . 12 ' -Snfr-1
IADDRESS ' — `20 _---
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CONTRACTOR : ---
TEST. Air 0 , Water p , Visual + Laboratory C7
I RESULT: Approved/1k, C'sapproved ❑ Pending ❑
I SKETCH:
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I INSPECTOR DATE
IOTE: Attach supplemental test data heret]
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UNIFIED SEWERAGE AGENCY NO. _ 4838 _
WASHINGTON COUNTY DATE �3
CITY OF_
APPLICATION FOR SEWER CONNECTION PERMIT
OWNER _ Otto Son__--
OWNER'S ADDRESS: _._._______
STREET
C,ry STATE Zw
BUILDING SITE: LOT_ _.__ BLOCK ADDITION
i AX LOT NO. TYPE OF OCCUPANCY _
ADDRESS _---.____ 8000 S.W. Pib!' e
DWF :R_LING UNITSFIXTURE UNITS _
SURCHARGE IF APPLICABLE
I RMIT FEE ___ --____.___ INSPECTION FEE ___ ____ TOTAL DEPOSITED __. 325
(NEV (EXISTINGf BUILDING SEWER SYSTEM __------ri�rd�---------.�__ _---_._
The Applicant agrees to comply with all rules and regulations of the Unified Sewerage Agency.
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APPLICANT
SEVVER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM.
0 DeteqpU
LINE SIZE -----_.___y _ -- ---__-__ INSTALLER
RECEIVED BY__.-___
IA NCV OA ITS AG N�
COMMENTS:
'This Application and permit expires in ninety (90) days. The amount paid will be forfeited
should expiration occur.