Permit • •
A: CITY OF TIGARD SEWER CONNECTION PERMIT
i ; DEVELOPMENT SERVICES PERMIT #: SWR2005 -00302
41 0 1 - s 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 9/29/2005
PARCEL: 2S103BC -00100
SITE ADDRESS: 12525 SW 121ST AVE ZONING: R -4.5
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: Connect existing house to sewer lateral. Reimb Dist #18 fee paid. Septic tank is to be pumped,
filled and inspected.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1.0
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner: FEES
MIKE & LIN STEVENS Description Date Amount
PO BOX 3527
WILSONVILLE, OR 97070 [SWUSA] Sewer Connection Fee 9/29/2005 $2,600.00
[SWINSP] Sewer Inspection Fee 9/29/2005 $35.00
Phone: 503 925 - 9100 Total $2,635.00
Contractor:
REQUIRED ITEMS AND REPORTS
Phone:
Reg #:
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"
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 -0100. You
may obta'n copies of these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issue. by: �u - • Permittee Signature: K .
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.