15400 SW 109TH AVENUE FNM "
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CiTYOFTiGARS► SEWER CONNECTION
COMMUNITY DEVELWMENT DEPARTMENT PPE RMIT
13125 SW Hall Blvd.Tigard,Oregon 9722398199 (503)639-4,171 PERMIT #. . . .. . . . : 6141394-0314
6 39-._41. 1 DATE ISSUED: 09/15/94
PARCEL: 2SI100(4-00600
SITE ADDRESS. . . : !".400 SW 109TH AVE
SUBbIVISION. . . . : WILLOW BROOK FARM ZONING: R-3. 5
BLOCK. . . . . . .. . . . : LOT. . . . . . . . . . . . . 4
TENANT !NAME. . . . . :
LISA NO. . . . . . . . . . : FIXIURE UNITS.
CLASS OF WORK. . . :AD!`1 DWELLING UNITS. . : 1
TYi-:'E OF USE:. . . . . :SF NO. OF BUILDINGS:
TNSTALL ryr-,E. . . . :BUSWR IMP'ERV SURFACE. . : Sf
Remarks: CONNFCT E) ISTING HOUSE TO SEWER -- SEPTIC MUST BE PUMPED, FILLED, &
INSIDECTED.
1,=.,%. Th e . ppl icant ro ses to constrftct extension of NaeVq,, c�Y,,eet to excee
d "s the
11
the mx>(i tt slope cello e for appru)(im,7�tely /3 feet with a stre lope ranyino
;t
hptween 16 A 17. 5"/..
Owner: FEES ——————---—————
BRUCE LAW type alnClUnt by date rerpt
15400 SW 109TH PRMT $ 2200. 00 JG 09/15/94
IN'-P) $ 3S. 00 JG 09/15/94•
TIGARD OR 9722.4
Phone #:
Contractor:
GVE
3815 COFFEY LN
NEWBERG OR 97132
r"'hone #° $ 2235. 00 TOTAL
Reg #. . : 54340
REQUIRED INSV,ECTIONE;
This Applicant agrees to comply with all the rules and regulations Sewer Inspection
of the Unified Sewage Agen-y. Thr permit expires 180 days from Septic lank Fil *"
the date issued. The tota! asoont paid will be forfeited if the ...........
permit expires. The Agency does not guarantee the accuracy of the
side sewer laterals. If the sewer is not located at the measurement
given, the installer shall prospect 3 feet in all directions from
the distance given. If not so located, the installer shall purchase
a "Tap and Side Sewer," Permit and the `)I en7",ill I I 1"tall a lAteral.
—7 1w
F'ermittee Signati.tre
s 1.i ed By
V
Cal for inspection 639-4175
T. . .
INSPECTION NOTICE �.~�✓
City of Tigard Building Department
13125 SW Stall Blvd. Tigard, Oregon 97223
Inspection Line (Reec-O-Phones 639-4175 Businoae Phone: 639-4171
Inspection: -------
Footing Plbg. Underaiab Mech. Rough-in (-Ippr/Sdwlk
Found. Plbg. Top Out Gas Line FINAL:
Poet./seam Struct. San. Sews'!?. Framing -Bldg.
c-__.
Poet/Ream Mach. Rain Drain Insulation -Plumb.
Plbg. Underfloor Nater Line 99 Gyp. Bd. -Mech.
Date Recpie/stad:
Addreeu: l i! "L Permit. is / 31 T
Builder: — - —THE FOLLOWING CORRRCTIONS ARS REQUIRED:
H
N
W
I
Inspectors `� - Dater —
APPROVED DI PPROVED APPROVED SU&IECT TO ABOVE
Call For Reinap.
INSPECTION NOTICE
City of Tigard Building Department
13125 SW Ball Blvd. Tigard, Oregon 9722.3
Insperction Line (Rec-O-Phone): 639-4175 Business Phone: 639-4171
Inspection:__—__ --------------
Footing Plbg. Underslab Mech. Rough-in Appr/Sdwlk
Found. Plbg. Top Out Gas Line 1'INAL:
Poet/Beam Struct. San. Sewer Framing --Bldg.
Post/Beam Mech. Rain Drain insulation -Plumh.
Plbg. Underfloor Water Lina Gyp. Bd. -Aech.
Dote Requested: 4 /�1 Timef AM ___PM
/, 5 v///JJ / y
Addressy ��L
: Parmit
Builder:_
THE FOLLOWING OORR$CTIONS ARE R$QU.RED:
a
hH
ex
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Inspector _ Date:
APPI:nVRD —_Y DISLPPROV$D APPROV$D StlBizor To ABOVt
_Call For P�_.,sp.
'TIGARD TICKET - G}--
SANG & GRAVEL, INC. NUMBER `
1 TONOIIIN AND STAFFORD QUARRIES I •
P.O 110X 41:1 . TUALATIN,OREGON 97062
PHONE 692 1800 C1 Jj
V . S. GUNTIiAL"'fINt3
TICKET 5105'
a pox 750 10/2104
9
SOLD 70: SH Nri00fJ QN 1410 DATE: 11 :57
TIME:
PENN. SUII?1A.TT -- Pl rkBd up , ORDER No.: UUb;I!O
JOB, } JOB NO.:
DELIVER TO'. y TRUCK NO.: 490
�. LOAD rrrNE
WEI NT OUANTITY AMOUNTS
m GROSS T RE NE'( Tr)NSICIAWYARDS MATERIAL DESCRIPTION tIN1TPTIC.F TUT Al-
iM,0 z Tao T?36o 7 FTUL, SANG.
Lal ! I
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+1
R E C W V E D Y•
,YE MAKE LIV IES INSIOF THE CURB LINE AND ON THE LOT AT CUSTOMER'S RISK ONLY AND ACCEPT NO RESPONSIBILITY WHATSOEVER FOR DAMAGES •
RESULTING OM SUCH DELIVERIES.ALL CLAIMS FOR SHORTAGES MUST BE MAnt IN WRITING WITHIN S DAYS FROM DATE OF DELIVERY.FREE UNLOADING
TIME OF IV MINUTES FOR A SINGLE TRUCK AND 20 MINUTES FOR A TRUCK AND TRAILER IR ALLOWED EXCESS T.ME WILL BE CHARGED AT EXISTING RATES
OFFICE COPY
STATE OF OREGON --WATER"ELL REPORT
gas required by ORS 537.765) (START CARD)# 65013
Instructions for cc•-mleting this report arc on the last page of this form.
(1) OWNER: Well Number 01 _ (9) LOCATION OF W F- L by lege!description:
Name Gus Contractin e^.- ssan novel coon; �5hinc�_tot�,,,;,ude Longitud, _
Address P.O. Box 760 _ Town,h p�WE'•�t N or S Rang�th E or W. WM.
qty Sherwood _ State Or. zip 9714 0 Section 10 _ ^�i1- - SF va
(2) TYPE OF WORK Tax r.ot � Lot Block Subdivision
❑New Well ❑Deepening i Alteration(repair/recondition) X Abandonment Strep.Address of Well(or(t_ a�address) 400 SW 1 09 t:)1
(3) DRILLN.IETHOD: TigaY:ir qtr.
[yA Rotary Air ❑RotaryMud ❑Cable ❑Auger (10) STATIC WATER LEVEL:
❑Other _ 68 ft.below land surface. Date 6-27-94
(4) PROPOSED USE: Artesian pressure-- Ib.per square inch. Date
®Domestic ❑Community ❑Ind,strial ❑Irrigation I l l► WATER BEARING ZONES:
[]Thermal ❑Injection ❑:.ivestock ❑Other
S) BORE HOLE CONSTRUC'.ION: Depth at which water was fret found *I I A
Special Construction approval❑Yes[3No Depth of CornpletCL Well 0 ft.
Explosives used ❑Yes ®No Type____ Amount _ _ _ From _— To Estimated Flow Rate SWC
HOLE SEAL _
Diameter From 7b MaterW Froal 7b Sacks or pounds __ ^
rr 1 0 1131 Cem jr S__
(12) WELL LO
Grwas seal placed: Method ❑A ❑B ❑C ❑D O E G;und Elevation _
® Other7'iginmie nine to bottom
Backfill placed from ft. to ft. Material _ Materia) From To SWL
Gravel P!dccd from ft, to ft. Size of grave
(6) ;:ASING/LINER: H/A
Diameter From 7b Gauge Steel Plastic Welded Threaded
Casing:— 6 sr — 2 . 250 [x) ❑ L* El _—
❑ ❑ ❑ ❑
-__ ❑ ❑ ❑ ❑
Liner: Non El El F-1
--- _ --- ❑ ❑ ❑ ❑
Final location of shoes) N1 A
7) PERFORATIONS/SCRE1s'NS: `
APerforations Method Air Rotary
❑Screens We Material
slot US blpe — — -- ——— -- ---From 7b 11 Number tMameter alar Clog Liner
20 x2l 160 ❑ --
-_- - -- - o �
1:1 El
Ul
(B) WELL TESTS: Minimum testing time IsIhour Datestarted 6-27-94 Completed 6--27-94�
Flowing (unbonded)Water Well Constructor Certification:
LO [_-]Pump ❑Bailer ❑Air ❑Artesian I certify that the rvark I performed on the construction,alteration,or abannonment
LLt nf this well is in compliance with Oregon water supply well construction standa•1s.
_ Yield gnVmtnDrawdowa OMI stem at — 11me Matenrls used st,d information reponed above are true to the best of my knowledge
A I hr. and belief.
ii WWC Number 553 _
Signed �� Date 6 L.$—�Y
T.mpersture of water_ Depth Artesian Flow Found --_ (banded)Water Well Con atnrctor a cation:
Was a water analysis done" ❑ Yes By whom_ I acceptresponsihility far the construction,alteratinn,or uhandonment work
Did any strata contain water not suitable for intended use? ❑ Ido little Ixr(°rmed on this well during the construction dates reported above. All work
performed daring this time is In compliance wilt.Oregon water supply well
[]Salty 1--]Muddy ❑Odor ❑Colored ❑Other —_ construction standards. This report is true to the best of my knowledge and belief
Depth of strata: _ _ WWC Number 1592—
Signed .
592—_
Signed _ ,, _ _Date
I=
ORIGINAL 3t FIRST COPY-WATER RESOURCES DEPARTMENT SECOND COPY-CONSTRUCTOR THIRD COPY-CUSTOMER
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10643 N.E.S mpson INVOICE Comp ete
Portland,Crogon Inclusinal
97220Waste
Romoval
Septic Tank Cleaning
Sump
DU Line Cleaning
022810
SANITATI N
DAA McInnis Ent.Ltd Co. '
I
(503) 253-7587
,�ustomer P.O. #__�3�L_�_w�_.iii_ Date 11!1-1 11-(4d
BillingName_GVS�fr1TRALU2(G 2—
Address P :1 ?GX 766
--- ,H`-.i iflr) ❑R 97140 - Job Site #
City_ State_ Zip Code
Ordered By "Ari i,F Phone#_�2�-GFls� Date _
JG'iLocation 1119 IJAVP __ _j,GARiF) _.L-IANKS--NEXI In EACH IJTNEI:�
Service Ca. _ $
Labor_ __ _ $
Pumping— ------gallons
Misc SEPI I C — - -- -$---- --- 280 . 00
2'.)8 . 00
Conditions of tank/Distribution Box
F}
TOTAL CHARGES 208 . 00
Schulz Sanitation is In no way responsible for damage to the septic tank or lids on the system.
TERMS:Net 10 days.1Y:%per month will be charged on past due accounts.(18%per annum)
Customer's Signature:
Service Driver's Signature
TERMS AND CONDI"i IO ON RUVERSE SIDS, REDE=MABLE;N MULTNOMAH COUNTY.