Permit W CITY OF TIGARD SEWER CONNECTION PERMIT
'' 1 COMMUNITY DEVELOPMENT Permit#: SWR2018-00268
Date Issued: 2/23/2022
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S110AC01101
Jurisdiction: Tigard
Site address: 11290 SW BULL MOUNTAIN RD
Project: Jacksons Food Stores 530 Subdivision: None Lot: None
Project Description: .06 EDU increase for a new convenience store and fueling facility.
Contractor: Owner: PACWEST ENERGY LLC
3450 COMMERCIAL CT
MERIDIAN, ID 83642
PHONE: PHONE: 208-888-6061
FAX:
FEES
Description Date Amount
Specifics: Sewer Inspection-Commercial 01/18/2022 $45.00
Sewer Connection Fee 01/18/2022 $339.00
Type of Use: COM
Class of Work: NEW
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: .06
Total $384.00
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 within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
Issued By: Permittee Signature: G `
Call 503.639. by 7:00 a.m.for the next available inspection date.
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.
Accumulative Sewer Tally
III s Tenant Name: JACKSONS SWR# 2018-00268
Site Address: 11290 SW BULL MOUNTAIN RD PLM# 2018-00512
TIGnxD Parcel#: 2S110AC01101
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value count capped#s value count added# added value total#s total values
Baptistry/Font 4 0 0 0 0 0
Bath: -Tub/Shower 4 0 0 0 0 0
-Jacuzzi/Whirlpool 4 0 0 0 0 0
Car Wash: -Each Stall 6 0 0 0 0 0
-Drive through 16 0 1 16 0 -1 -16
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
F.ye Wash 1 0 0 0 0 0
Floor Drain/Sink: -2 inch 2 0 0 11 22 11 22
-3 inch 5 0 3 15 1 5 -2 -10
-4 inch 6 0 0 0 0 0
-Car Wash 6 0 3 18 0 -3 -18
Garbage Disposal:
-Domestic(to 3/4 HP) 16 0 0 0 0 0
-Commercial(to 5 HP) 32 0 0 0 0 0
-Industrial(over 5 HP) 42 0 0 0 0 0
Ice Machine/Refrigerator Drain 1 0 2 2 3 3 1 1
Living Unit 16 0 0 0 0 0
Oil Sep(Gas Station) 6 0 0 1 6 1 6
Rec.Vehicle Dump station 16 0 0 0 0 0
Shower: -Gang(per head) 1 0 0 0 0 0
-Stall 2 0 0 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 3 6 5 10 2 4
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 2 6 2 6 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer-Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet-Toilet 6 0 2 12 3 18 1 6
Urinal 6 0 0 1 6 1 6
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 16 75 27 76 11 1
Current Fixture Value I divided by 16= 0.063 Current EDU 1 EDU= $5,650.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 1 divided by 16= 0.063 over (under) $ 339.00
Enter EDU Change Here 0.060 *
*Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01.
Notes:
Authorized Name/Signature: BRANDEN TAGGART Date: 12/5/2018
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist,this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
I:\Building\Sewer Tally\SewerTallySheet_5500_070117.xlsx