Permit •
CITY TIGARD SEWER CONNECTION PERMIT
.' DEVELOPMENT SERVICES PERMIT #: SWR1999 -00249
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' °' i 13 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 11/22/1999
SITE ADDRESS; 11585 SW 67TH AVE PARCEL: 1S136DD-00800
SUBDIVISION: WEST PORTLAND HEIGHTS ZONING: MUE
BLOCK: LOT: 003 JURISDICTION: TIG
TENANT NAME: FAMILY BAPTIST CHURCH
USA NO: FIXTURE UNITS: 53
CLASS OF WORK: ADD DWELLING UNITS: 3
TYPE OF USE: COM NO. OF BUILDINGS: 1
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: Disconnecting from septic tank and connecting to sewer. Sewer tally sheet provided by applicant to
show total existing plumbing fixtures.
Owner:
FEES
FAMILY BAPTIST CHURCH Type By Date Amount Receipt
11585 SW 67TH
TIGARD, OR 97223 • PRMT BON 11/22/199E $6,900.00 99- 319953
INSP BON 11/22/199E $45.00 99- 319953
Phone: Total $6,945.00
Contractor:
Phone:
Reg #:
Required Inspections
Sewer Inspection •
Septic Tank Filled
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This Applicant agrees to comply with all the rules and regulations of the Unified Sewage Agency. The permit expires
180 days from the date issued. The total amount 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 Agency will install a lateral. ATTENTION: Oregon law requires you to follow rules adopted
by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0080.
You may obtain •• pies of these rules or direct questions to OUNC by calling (503) 246 -1987.
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Issued by: ` % / � t Permittee Signature:A(4
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
`` = " * - Accumulative Sewer Tally •
enant Name: This SWR#
,ddress: //$75 17 J2 1?LZ3 This PLM #:
ixture Value ✓ Previous Previous Credits Capped Fixtures Fixtures New total New
• # Value Capped off value added # added #s total
Count . off #s count _ value values
;aptistry/Font 4 .
Lath - Tub /Shower 4 -
- JacuzziNVhirtpool 4 •
;ar Wash - Each Stall ' 6 .
- Drive Through 16 -
:uspidor/WaterAspirator 1 `
)ishwasher - Commercial 4 _ .
•
- Domestic 2 .
Drinking Fountain 1 / / ,
Eye Wash 1 ,
Root Drain/sink - 2 inch 2 / ?i
- 3 inch 5 ,
- 4 inch 6
- Car Wash Dm 6 ,
Garbage Disposal 16
- Domestic (to 3/4 HP) _
- Commercial (to 5 HP) 32
- Industrial (over 5 HP) 48 • ,
Ice Machine /Refrigerator Drains 1
Oil Sep (Gas Station) 6
Rec. Vehicle Dump Station 16 ,
•
Shower - Gang (Per Head) 1
- Stall 2 7
Sink - Bar /Lavatory 2 - 5 /0
- Bradley 5
- Commercial 3 ✓ 6 - -
- Service 3 .
Swimming Pool Filter 1
Washer - Clothes 6 ,
Water Extractor 6 .
Water Closet - Toilet 6 5 , 3 0
Urinal 6 C
TOTALS 53
. by 33 EDU 'J r l�'� fXEV�vu���- vlN
Total fixture values: . divided b 16 =
a� C . — 4l/u» C'c.)_" y '1014!
HISTORY ;- x5A I t ,, e- ,,Pl AlAve ..c v4.0 vP -
PLM# EDU# SWR# PLM# EDU# 1 SWI
PLM# EDU# SWR# PLM# EDU# SWR#
PLM# - EDU# SWR# PLM# EDU# SWR#
PLM# EDU# SWR# PLM# EDU# SWR#
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