Permit A ll'ib CITY OF TIGARD SEWER CONNECTION PERMIT
l DEVELOPMENT SERVICES PERMIT #: SWR2000 -00166
- 13125 SW H all Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 6/23/00
SITE ADDRESS; 14865 SW 104TH AVE PARCEL: 2S111 CB -01309
SUBDIVISION: DEL MONTE SUBDIVISION NO.2 ZONING: R -3.5
BLOCK: LOT: 018 JURISDICTION: TIG
TENANT NAME:
USA NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: Connection of existing house to newly installed sewer lateral. Reimbursement fee on this date,
receipt #0003234. Septic tank must be pumped, filled and inspected or removed.
Owner:
FEES
KNUTSON, GENE H MARION B Type By Date Amount Receipt
14865 SW 104TH
TIGARD, OR 97223 PRMT DEB 6/23/00 $2,300.00 0003234
INSP DEB 6/23/00 $35.00 0003234
Phone: Total $2,335.00
Contractor:
Phone:
Reg #:
Required Inspections
Sewer Inspection �` _
Septic Tank Filled (��� v
V `
cS
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 95 00 -0080.
You may o• ain .• pies of these rules or direct questions to OUNC by calling (503) 246 -1987.
Issued by J7 . A4&44 L 1 Permittee Signature: 1 s . , w
■M..J
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next ' usiness day
T om- A AFFORD ABLE
SEPTIC SERVICE
�. P.O BOX 1130
WILSONVILLE, OR 97070
(503) 1939 FAX (5O3) 57047
CUSTOMERS ORDER NO. PNE (
1 _ .'"C? 0
NAMF9 1 C- k cq va4 i
ADDRESS
/ 9 3' 00 , w o or\ Avt.
• SOLD BY CASH C.O.D. CHARGE ON ACCT. MDSE. RET'D. PAID OUT
Qt CO.
OTY. DESCRIPTION PRICE AMOUNT
no
��. c. .
slo
to .gel Or
TAX
RECEIVED BY
TOTAL
All claims and returned goods MUST be accompanied by this bill.
r ToRFea� sz THANK YOU
�'4 ' 1 - OO -SRS!