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Permit CITY T I GA R D SEWER CONNECTION PERMIT '' l Jl l . DEVELOPMENT SERVICES DATE SSUED: SW R2004 -00116 k ` - - ' 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 SITE ADDRESS; 09021 SW BLACKOAKS LN PARCEL: 2S111AB -GP383 SUBDIVISION: GREENSWARD PARK NO. 3 ZONING: R - 4.5 BLOCK: LOT: 083 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: Sewer connection for new SF Owner: FEES FOUR D CONSTRUCTION CO PO BOX 1577 Description Date Amount BEAVERTON, OR 97075 [SWUSA] Swr Connect 5/12/2004 $2,400.00 [SWUSA] Swr Connect 5/12/2004 $0.00 Phone: 503 -590 -0805 [SWINSP] Swr Inspect 5/12/2004 $35.00 [SWINSP] Swr Inspect 5/12/2004 $0.00 Contractor: Total $2,435.00 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" 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 obtain copies of these rules or direct questions to OUNC by calling (503) 246 -6699. Issued by: Permittee Signature: /� / Call ( 03) 639 -4175 by 7:00 P.M. for an inspection needed the next usiness day