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Permit
CITY TIGARD SEWER CONNECTION PERMIT I A DEVELOPMENT SERVICES PERMIT #: SWR2003 -00223 � 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 7/1/03 SITE ADDRESS; 13535 SW 72ND AVE 140 PARCEL: 2S101 DC -00200 SUBDIVISION: 72ND AVE OFFICE BUILDING ZONING: C - P BLOCK: LOT: JURISDICTION: TIG TENANT NAME: USA NO: FIXTURE UNITS: CLASS OF WORK: ALT DWELLING UNITS: TYPE OF USE: COM NO. OF BUILDINGS: INSTALL TYPE: BUSWR IMPERV SURFACE: Remarks: Sewer tally. Owner: FEES PACIFIC NW PROPERTIES LTD PTNSHP Description Date Amount 9665 SW ALLEN BLVD STE 115 BEAVERTON, OR 97005 [SWUSAJ Swr Connect 7/1/03 $288.00 [SWUSA] Swr Connect 7/1/03 $0.00 Phone: Total $288.00 Contractor: Phone: Reg #: Required Inspections 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 Permittee Signatur Issued by: � �/ , t(ttn Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day Accumulative Sewer Tally Tenant N .r� "`. �uiil Insurance This SWRA 2003 -00223 Site Address: 13535 SW 72nd This PLM# 2003 -00315 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 0 0 0 - 3 inch 5 0 0 0 0 0 - 4 inch 6 0 0 0 0 0 - Car Wash Drn 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 1 2 1 2 - 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 0 0 0 Urinal 6 0 0 0 0 0 Previous EDU Count 9.2 147.2 147.2 Capped EDU Credit 0 TOTALS 0 147.2 0 0 1 2 1 149.2 Current Fixture Value 149.2 divided by 16 = 9.3 Current EDU 1 EDU = $ 2,400 Previous Fixture Value 147.2 divided by 16 = 9.2 Previous EDU Change 2 divided by 16 = 0.1 over (under) $ 288.00 Enter EDU Change Here 0.12 HISTORY Notes: PLM# EDU# SWR# PLM# EDU# SWR# PLM# EDU# SWR# Name: . �i % / �.� Date: 1' /— e.73 Signature of person that calculated this tally sheet and date perfromed is required