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Permit C ITY OF TIGARD SEWER CONNECTION PERMIT Awtrio �4s DEVELOPMENT SERVICES PERMIT #: SWR2002 -00332 Ail- . .� I- ' 13125 SW���aHaal�ll Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 3/28/03 SITE ADDRESS; 1=SW 68TH AVE PARCEL: 2S101AA -08700 SUBDIVISION: WEST PORTLAND HEIGHTS ZONING: MUE BLOCK: LOT: 029 JURISDICTION: TIG TENANT NAME: ROTH OFFICE BUILDING USA NO: FIXTURE UNITS: CLASS OF WORK: NEW DWELLING UNITS: TYPE OF USE: COM NO. OF BUILDINGS: INSTALL TYPE: LTPSWR IMPERV SURFACE: Remarks: Sewer connection for new office building. Owner: FEES ROTH, J T JR + THERESA Description Date Amount 12600 SW 72ND AVE, STE 200 TIGARD, OR 97223 [SWUSA] Swr Connect 3/28/03 $5,750.00 [SWUSA] Swr Connect 3/28/03 $0.00 Phone: [SWINSP] Swr Inspect 3/28/03 $45.00 [ SWINSP] Swr Inspect 3/28/03 $0.00 Contractor: Total $5,795.00 Phone: Reg #: Required Inspections bf.ui EP 1 NgP This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. 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" Perm Issued by: ,� � # A Permittee Signature: Call (503) 639 -4175 by 7:00 P.M. for an inspection needed t e next busine ay Accumulative Sewer Tally T,enantisk;giet )Toth Office Built New Building This SWR/a 2002 -00332 Lfdms®: —12595 SW 68th Ave. This PLM# 2002 -00468 /257/ Fixture Value Previous Previous Credits Capped Fixture Fixture New New # value capped off value added added total total count off #s count # value #s values Baptisery/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 0 0 0 0 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 Eye Wash 1 0 0 0 0 0 Floor Drain /Sink - 2 inch 2 0 0 4 8 4 8 - 3 inch 5 0 0 0 0 0 - 4 inch 6 0 0 0 0 0 - Car Wash Drq 6 0 0 0 0 0 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) 48 0 0 0 0 0 Ice Machine /Refrigerator Drain 1 0 0 0 0 0 Oil Sep (Gas Station) 6 0 0 0 0 0 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 - Bar /Lavatory 2 0 0 4 8 4 8 - Bradley 5 0 0 0 0 0 - Commercial 3 0 0 0 0 0 - Service 3 0 0 0 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 0 4 24 4 24 Urinal 6 0 0 0 0 0 Previous EDU Count 0 0 0 Capped EDU Credit 0 TOTALS 0 0 0 0 12 40 12 40 Current Fixture Value 40 divided by 16 = 2.5 Current EDU 1 EDU = $2,300.00 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change 40 divided by 16 = 2.5 over (under) $ 5,750.00 Enter EDU Change Here 2.5 HISTORY EDU# SWR# PLM# Notes: PLM# EDU# SWR# PLM EDU# SWR# Name: - 142 ,e 4,/ ( Date: 4-'7 — 6 -.0.2. / Signature of person that calculated this tally sheet and date perfromed is required