Permit CITY TIGARD SEWER CONNECTION PERMIT
1444 4 1 111j DEVELOPMENT SERVICES PERMIT #: SWR2000 -00032
4 � ' f l 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED841 2,/i 0) 60
SITE ADDRESS; 12911 SW 113TH PL PARCEL: 2S103AC -FON04
SUBDIVISION: FONNER WOODS ZONING: R -4.5
BLOCK: LOT: 004 JURISDICTION: TIG
TENANT NAME: SELLICK, LEE & BETSY
USA NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS: 1
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: New SF - Path I
Owner: FEES
SELLICK, LEE & BETSY Type By Date Amount Receipt
8780 SW BOMAR CT
TIGARD, OR 97223 PRMT GEO 03/07/200C $2,300.00 0000488
INSP GEO 03/07/200C $35.00 0000488
Phone: Total $2,335.00
Contractor:
Phone:
Reg #:
Required Inspections
Sewer Inspection
ORU3INAL
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 copies of these es or ' ect questions to OUNC by calling (503) 246 -1987.
Issued by: = Permittee Signature:
Call (503) 639 - 175 by 7:00 P.M. for an inspection needed the next business day