Permit CITY TIGARD SEWER CONNECTION PERMIT
Ifk DEVELOPMENT SERVICES PERMIT #: SWR2002 -00099
-- 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 5/2/02
SITE ADDRESS; 17005 SW 92ND AVENUE PARCEL: 2S114A0 -01500
SUBDIVISION: ZONING: R -12
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME:
USA NO: FIXTURE UNITS: 122
CLASS OF WORK: NEW DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:.
Remarks: 7.6 EDU's for new Restroom with concession - Phase II of Cook Park Master Plan expansion.
Owner:
FEES
TIGARD, CITY OF Type By Date Amount Receipt
13125 SW HALL
TIGARD, OR 97223 PRMT DEB 5/2/02 $17,480.00 JE #
Total $17,480.00
Phone:
Contractor:
Phone:
Reg #:
Required Inspections
Sewer Inspection
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" Perm
Issu d by. • 1,4 jrj� i V ._•! Permittee Signature:
Call (503) 6 9 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally
Tenant Name^ Cook Park - Restroom w /concession This SW Rt 2002 -00099
Site Address: 17005 SW 92nd Ave This PLM# '2002-00051
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 2 2 2 2
Eye Wash 1 0 0 _ 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 15 30 15 30
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drr 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 1 1 1 1
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 10 20 10 20
- Bradley 5 0 _ 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 3 0 0 3 9 3 9
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 10 60 10 60
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 41 122 41 122
Current Fixture Value 122 divided by 16 = 7.6 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 122 divided by 16 = 7.6 over (under) $ 17,480.00
Enter EDU Change Here 7.6
HISTORY
Notes: New PLM# EDU# SWR#
- - I # EDU# SWR#
PLM# EDU# SWR#
Name: L ,'� ■ -� -r .., Date: / /,2--
Signature of person that calculated this tally sheet and date perfromed is required