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Permit k_ BUILDING PERMIT CITY OF TIGARD PERMIT #: BUP2004 -00079 �I DEVELOPMENT SERVICES DATE ISSUED: 3/2/04 � --' 13125 SW Hall Blvd.. Tigard, OR 97223 (503) 639 -4171 SITE ADDRESS: 07865 SW BONITA RD PARCEL: 2S1126A 00500 SUBDIVISION: ZONING: R - BLOCK: LOT: JURISDICTION: TIG REISSUE: FLOOR AREAS EXTERIOR WALL CONSTRUCTION CLASS OF WORK: DEM FIRST: sf N: S: E: W: TYPE OF USE: SF SECOND: sf PROJECT OPENINGS? TYPE OF CONST: 5N : sf N: S: E: W: OCCUPANCY GRP: R3 TOTAL AREA: 0 sf ROOF CONST: FIRE RET? OCCUPANCY LOAD: BASEMENT: sf AREA SEP. RATED: STOR: HT: ft GARAGE: sf OCCU SEP. RATED: BSMT ?: MEZZ ?: REQD SETBACKS REQUIRED FLOOR LOAD: psf LEFT: ft RGHT: ft FIR SPKL: SMOK DET: DWELLING UNITS: FRNT: ft REAR: ft FIR ALRM : HNDICP ACC: BEDRMS: BATHS: IMP SURFACE: PRO CORR: PARKING: VALUE: Remarks: Demo 969 sq ft SF residence. SDC credits for TIF, Parks, Water Quantity & Sewer to be applied to new construction. Owner: Contractor: MATRIX DEVELOPMENT CORPORATION DEREK L BROWN & ASSOCIATES INC 12755 SW 69TH AVE 9500 SW BARBUR BLVD #220 100 PORTLAND, OR 97219 PORTLAND, OR 97223 Phone: Phone: 503 - 892 -8758 Reg #: LIC 58699 FEES REQUIRED INSPECTIONS Description Date Amount Ersn Cntrl 681 - 4444 [TAX] 8% State Surchart 3/2/04 $5.00 Cap Sewer Line Insp [ERPRMT] Erosion 3/2/04 $26.00 Final Inspection [ERPLN] Ero Plck -USA 3/2/04 $8.45 [EROSN] Ero Plck -COT 3/2/04 $8.45 (additional fees not listed here) Total $110.40 This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow the 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 a copy of these rules or direct questions to OUNC by calling (.503) 246- 6699.9r 1- 800 - 332 -2344. f ( Isst.(ed J - Y • Perm itfe'e --'- -- Signature: Call 639 -4175 by 7 p.m. for an inspection the next business day .. • , .. ,.- . ..„. . Buildink PermitApp fiEQEIVED . • _ . . ,. FOROFFICE:USEONLY City of Tigard Received , Permit No • • - ;. 1,44 --eria 13125 SW Hall Blvd., Tigard, OR 97223 MAR !P 2 2004' ko Date/By: ey" • Plan Review Phone: 503.639.4171 , Fax: 503.598.1960. /htfi 1 ,i,%\ Date/By: Other Permit: Inspection Line: 503.639.4175 ulTY OF TIGAR r_ Date Ready/13y: Juris: Ed See Attached Checklist for Internet: www.ciligard.or.us BUILDING DIVIS i 1 Notified/Method: S 1 a Supplemental information PL iii ,t;Cel — 0 0 op 5 ! :4„,? . PEP '... ',' & 4.1 1 i - 0 " ^..,?..?i'..1". 4,i.'r'i4,:-......,:‘,..,..-."41'4;•?;,', it*, V: :..:!!!'!'.,,,-. •"..,,,', :v :• ' -.; •.: ;;, '.":,...., .,„,. ..... ... „ , ,„ „,,, .. . .,, . , . ...- ,,,, .. „ „ . .. 0 New construction (Demolition Permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all 0 Addition/alteration/replacement 0 Other: equipment, materials, labor, overhead, and the profit for the ektid'ijiii .',J,'.,,k",i...:-..j.'-;,;-,•„11..k.,',..1"40,;;; work indicated on this application. :1, „ -,',.• ... ,- ,,,•,',-.. . ,..,!..• CONSTRUCTIO —,., ...„,,,„ •.,,,,,,,,.';%!-r- $ 4 000.co - and 2-family dwelling Accessory building 1g3 . Commercial/industrial [3 Multi-family Valuation: ' Number of bedrooms: I Number of bathrooms: 0 Master builder 0 Other: . , ,,, IA , ' ,,,, ' ,,,,K, `''''''''''''''' , '' • .. ' ,. .I , .' ■ ,.. !!srANVILOCATION it:':.:'''''S:: -rV .!..r7..;•'4,:.•...,':1,;,::•: Total number of floors: *Iltaqii.6 1i . = ,, r.,...1. ■■•,.::.4 2E. ::.":1. '..'St ..' (' '',,' ',', ',i• --: '.:',:, ..rf■ i.1° Job site address: 7 -e>.,.i crPt rec. etrvi, New dwelling area: square feet City/State/ZIP: — r - 1 G , ate Garage/carport area: square feet Suite/bidgJapt no.: Project name: T -vi-A-- 1r/4.4..) )-(ov.‘i S Covered porch area: square feet Cross street/directions to job site: Deck area: square feet Lt 4>eS Chi CC/44-fitee Or low 17-por A's-f)3 F Other structure area: square feet Cgic.PAL ?-c3A 12EQIIIIt.ED:DATA:COINTREA( ALAISE,CRECKLIST Subdivision: Lot no.: Permit fees* are based on the value of the work performed. Indicate the value (rounded to the nearest dollar) of all Tax map/parcel no.: equipment, materials, labor, overhead, and the profit for the :15jegabl;fga :.'..„: work indicated on this application. •:-...,--..!--n-,1:-..E-e.,.z?„:7,-.--:-..t.-,...•,!,:r.--44.--,,,,t6i,i-i---,..,,....,-:=.,-..-,.,,,,..,,,,,..tp,,,,,,,,:„.„,,,,,i,,,,..tiw,,,,,,,,,.....„.kt„a;i'.14-..;- 7.. '•;---' - ":A..`,` l': ,- -cr. *AND & cr SigerLiE get-r‘it4 t-(evt-E Valuation: $ 4,r Cs ol.) .ceGuIrAz 749,3' Existing building area: square feet New building area: square feet g;1111111V.It ill,'*-t, clttiOnte.t Titl*I■IPITA,t;;;;Af5;717,;7::;',:,5 Number of stories: Name BOO 1 rb4 — ren.ilogeir4-S (-LZ., Type of construction: 1 . Address: ( -Ica) S. (4.,,,,tuv,_, g)o, Su,,, zu) Occupancy groups: . City/State/ZIP: 1 OW- ° I7 1- L Existing: Phone: ( al) Got z.-- 5-tc9 Fax: ( 50 3 )892- - oki New: `,...FikiiiieUfk,--7, i!,i4g1::P.1-t.44 t 6,:ak,a6C iiiiiijWiF,WL:i:: :A,-ii-',: :,.--,.,...,, - 1 , 4 . ,:,:si, , p;; ;:, :--; ;:' .: . '•', : , . ::; PK047% ' • •'''''''''' h:' •.."-...:•':,-:'"'":*-,: • i - Business name: \ lb4 . a,E14, L, ak ft, k%e I i p t .Ls All contractors and subcontractors are required to be licensed with the Oregon Construction Contractors Board Contact name: AAh IftWS'oj under ORS 701 and may be required to be licensed in the Address: 1 Soo .. Q . .) V-ft_lu / u15 t)i 7 jurisdiction in which work is being performed. If the A / applicant is exempt from licensing, the following reasons City/State/ZIP: ? t ont, 9 - rill apply: Phone: (cc)3 ) .epl z _ els -8 Fax: : A ) E se-4( E-mail: .orel ot r V a, dklprou)n etc 4 r erv" • : t■ 1,-;5,13'..wRi; .1 i .z. we- - ' w - r - r ,;'. •..4 0 -Q : ,.;t:.' i,'.'• 1 i ,-,-,i,f i,:!,,,e lc c . Business name: \t)eseec., I.- (7.-43 4 - Asxt4-1, Address: - 4C.- 3,) Kot 2 KL, .c _20 Please refer to fee schedule. l . City/State/ZIP: kxurI t aa_ ct?2„(ct • . Fees due upon application Phone: (503 ) apt 2,.-vis- Fax: (01 ) Viz -- 8S11( 58 6/9 Amount received CCB lic.: Date received: Authorized signa e: • This permit application expires if a permit is not obtained within 180 days after it has been accepted as complete. Print name- tilt Date: 2_76 1:7/ * Fee methodology set by Tri-County Building Industry Service Board. 1:1Building1Permits1BUP-PemitApp.doc 12/03 440-4613T(11/07JCOM/WEB) • nd Two -Famil. Dwellin Y • • . One- a y g Building Permit Application Checklist FOR OFFICE USE. ONLY . - . City of Tigard R ece i ve d Permit No.: �' ' $ DaceBy:'. 13125 SW Hall Blvd., Tigard, OR 97223 Associated permits: Phone: 503.639.4171 Fax: 503.598.1960 /I » ` A , 24- Hour Inspection Line: 503.639.4175 _, J� 1 ❑ Electrical ❑ Plumbing ❑ Mechanical . Internet: www.citigard.or.us ❑ Other: THE FOLLOWING ITEMS ARE REQUIRED FOR PLAN REVIEW - Yes No N/A 1 Land use actions completed. See jurisdiction criteria for concurrent reviews. • El ❑ ❑ 2 Zoning. Flood plain, solar balance points, seismic soils designation, historic district, etc. El ❑ El 3 Verification of approved plat/lot El ❑ El 4 Fire district approval required. Name of district: El ❑ ❑ 5 Septic system permit or authorization for remodel. Existing system capacity . El ❑ El - 6 Sewer permit. 7 Water district approval. ❑ ❑ ❑ 8 Soils report. Must carry original applicable stamp and signature on file or with application. ❑ ❑ El 9 Erosion control ❑ plan ❑ permit required. Include drainage -way protection, silt fence design and location of catch- ❑ ❑ ❑ basin protection, etc. 10 3 Complete sets of legible plans. Must be drawn to scale, "showing conformance to applicable local and state El ❑ ❑ building codes. Lateral design details and connections must be incorporated into the plans or on a separate full -size sheet attached to the plans with cross references between plan location and details. Plan review cannot be completed if copyright violations exist. 11 Site/plot plan drawn to scale. The plan must show lot and building setback dimensions; property corner elevations (if ❑ ❑ El there is more than a 4-ft. elevation differential, plan must show contour lines at 2 -ft. intervals); location of easements and driveway; footprint of structure (including decks); location of wells/septic systems; utility locations; direction indicator, lot area building coverage area; percentage of coverage; impervious area existing structures on site; and surface drainage. 12 Foundation plan. Show dimensions, anchor bolts, any hold -downs and reinforcing pads, connection details, vent size ❑ ❑ ❑ and location. 13 Floor plans. Show all dimensions, room identification, window size, location of smoke detectors, water heater, El ❑ ❑ furnace, ventilation fans, plumbing fixtures, balconies and decks 30 inches above grade, etc. 14 Cross section(s) and details. Show all framing - member sizes and spacing such as floor beams, headers, joists, sub- ❑ ❑ ❑ floor, wall construction, roof construction. More than one cross section may be required to clearly portray construction. Show details of all wall and roof sheathing, roofing, roof slope, ceiling height, siding material, footings and foundation, stairs, fireplace construction, thermal insulation,;etc.. 15 Elevation views. Provide elevations for new construction; minimum of two elevations for additions and remodels. El ❑ ❑ Exterior elevations must reflect the actual grade if the change in grade is greater than four foot at building envelope. Full -size sheet addendums showing foundation elevations with cross references are acceptable. - 16 Wall bracing (prescriptive path) and/or lateral analysis plans. Must indicate details and locations; for non- El El El prescriptive path analysis provide specifications and calculations to engineering standards. - 17 Floor /roof framing. Provide plans for all floors/roof assemblies, indicating member sizing, spacing, and bearing El El El locations. Show attic ventilation. 18 Basement and retaining walls. Provide cross sections and details showing placement of rebar. For engineered El ❑ El systems, see item 22, "Engineer's calculations." - 19 Beam calculations. Provide two sets of calculations using current code design values for all beams and multiple joists ❑ ❑ ❑ over 10 feet long and/or any beam/joist carrying a non - uniform load. 20 Manufactured floor /roof truss design details. _ r ❑ ❑ 21 Energy Code compliance. Identify the prescriptive path or provide calculations. A gas - piping schematic is required ❑ ❑ El for four or more appliances. 22 Engineer's calculations. When required or provided, (i.e., shear wall, roof truss) shall be. stamped by an engineer or El El Cl architect licensed in Ore:on and shall be shown to be applicable to the .ro'ect under review. JURISDICTIONAL SPECIFICS 23 'Five (5) site plans are required for Item 11 above. Site plans must be 8 -1/2" x 11" or 11" x 17 ". El ❑ ❑ 24 Two (2) sets each are required for Items 16, 19, 20 and 22 above. ❑ • ❑ ❑ 25 Building plans shall not contain red lines or tape -ons. "Mirrored" building plans will not be accepted. El El El 26 "Reversed" building plans must meet criteria outlined in the Permit & System Development Fees document. ❑ ❑ El 27 "Drawn to scale" indicates standard architect or engineer scale. ❑ ❑ ❑ 28 Site plan to include tree size, type and location per approved project street tree plan (if applicable), and City of Tigard ❑ • El ❑ Street Tree List. 29 Site plan to include tree protection measures as required by conditions of approval. El El " El 30 A Clean Water Services' Sensitive Area Pre - Screening Site Assessment form is required for all building additions, ❑ ❑ El including decks, patio covers (over non - impervious surface) and accessory structures to existing residential dwellings on a lot of record approved prior to September 9, 1995. i:\Building\Pernuts \One- Two-FamilyChecklistdoc 12/03 - - - - . • * * ** *STATEMENT * * * ** A.M. JANNSEN WELL DRILLING CO STATEMENT DATE: May 31 04 21075 SW TV Hwy ACCOUNT NUMBER: RU3737 ALOHA, OR ACCOUNT PHONE : (50,3` -) 64 37 97006 PHONE :(503) 649 -5563 RUTAN CONSTRUCTION INC 21515 NW CHERRY LN. HILLSBORO, OR 97124 TYPE CODES: IN= INVOICE IT= INTEREST CR= CREDIT CA= PAYMENT INVOICE DATE TYPE INVOICE NO. AMOUNT e • . , _ X59-1 859 -r09 - fr { f 05 22 04 IN 9603 910.00 05 31 04 IN 9613 1,205.00 • ti ' I ( ___ Z!�J IL I; J - 9 ZO4 RUTAN CONSTRUCTION, INC. PLEASE PAY THIS AMOUNT > 2,9-65-.00 c 7//.5 -7, PAYMENTS RECEIVED AFTER THE 25th MAY NOT SHOW ON THIS STATEMENT CURRENT 30 D$Y 60 DAYS 90 DAYS 2,115.00 50.00 0.00 0.00 • * * ** *STATEMENT * * * ** A.M. JANNSEN WELL DRILLING CO STATEMENT DATE: Jun 30 04 21075 SW TV Hwy ACCOUNT NUMBER: RU3737 ALOHA, OR ACCOUNT PHONE : (503) 643 -3737 97006 PHONE:(503) 649 -5563 RUTAN CONSTRUCTION INC 21515 NW CHERRY LN. HILLSBORO, OR 97124 TYPE CODES: IN= INVOICE IT= INTEREST CR= CREDIT CA= PAYMENT INVOICE DATE TYPE INVOICE NO. AMOUNT 04 29 04 IN 9591 850.00 06 24 04 CA 9591 850.00- 05 22 04 IN 9603 910.00 05 31 04 IN 9613 1,205.00 IfH JU L I 6 2004 PLEASE PAY THIS AMOUNT > 2,115.00 PAYMENTS RECEIVED AFTER THE 25th MAY NOT SHOW ON THIS STATEMENT CURRENT 30 DAYS 60 DAYS 90 DAYS 1,205.00 910.00 0.00 0.00 A. M. JANNSEN WELL DRILLING CO., INC. 21075 SW TUALATIN VALLEY HWY. ALOHA, OR 97006 (503) 649 -5563 INVOICE BILL TO: RUTAN CONSTRUCTION DATE: MAY 31, 2004 21515 NW CHERRY LANE HILLSBORO, OR 97124 INVOICE NO. 9613 WORK ORDER #1562 ABANDON 8" STEEL CASED WELL @ 20600 NW AMBERWOOD DR. MOBILIZATION DRILLING EQUIPMENT $ 600.00 MATERIALS: 32 SKS. CEMENT @ $15.00 /SK. 480.00 START CARD FILING & ABANDONMENT REPORT 125.00 TOTAL INVOICE $1205.00 1% Finance Charge per month on Past Due Accounts _' 1 t, JUN - 8 MrtN CONS T RUCTION INC. . i �=� z)V Maj 04 04 01:53p Derek Brown & Assoc. (S71] 233-0071 p.3 . . . . STATE OF OREGON .WATER SUPPLY WELL REPORT WELL I.D. # L as required by ORS S37,7()5t START CARD # ". •:,.'".: --1 . Instructions for completing this report are on the last page of this form. (1) LAND OWNER Well Number, (9) LOCATION OF WELL by legal description: County. ''''''--):'- f Longitude Address ,'':.--; '.: :: _ . .' ';"::','"7""'.:• .:-.: 7 .'-: . ..' .• .'I. Township ,-.:-.' N or S Range C t. E or W. WM. City l',7',;:l .:• State '.."..' Zip '.:','. Section ' ' • 1/4 '-;-.: 1/4 (2) TYPE OF WORK Tax Lot :2.: C ,: _ Lot Block Subdivision CI New Well 0 Deepening 0 Alteration (repair/recondition) 0 Abandonment Street Address of Well or nearest address) - - - ' :•:! ':- -) (3) DRILL METHOD: . .1-1.-. -" : .-- , - ,---- - - 0 Rotary Air C RotiTy Mu C Cable 0 Auger (10) STATIC WATER LEVEL: 1 1 17 Other _. -----' ' ft. below land surface. I (4) PROPOSED USE: Artesian pressure lb. per square inch Date 0 Domestic 0 Community 0 Industrial 0 Irrigation (11) WATER BEARING ZONES: .., I e .---- s ■ 1 CI Thermal C Injection III Livestock 0 Other t t ,-` (5) BORE HOLE CONSTRUCTION: Depth at which water was first found ,.,.--- Special Construction approval 0 Yes 1.7.3 No Depth of Completed Well :—__. _It. , .., Egimated Flow - R ' a - t - e SWL Explosives used C Yes p No Type _Amount .--- IlOLE SEAL. --- Diameter From To Material From To Sacks or pounds , ...--- 1---.' ..-- , ... . .i :'' :ii •--- - i'") ( 3 1,7'.7.7, _ _.,, . I • _ '(12) WELL LOG: How was seal placed: Method 0 A 0 B 0 C C D C E - Ground Elevation Other 3.1..:-.1 _;:. ! . ;y Backlit' placed from ft. to ft. Material Material From To SWL Gravel placed from ft. to . ft. Siec of gravel 7. ':', -n..7. . ...:/c-: - .,r1r:rnt.7 , . (6) CASING/L1NER: .., - '...::::-... Diameter From lb Gauge Steel Plastic Welded,- Threaded . in. -,- - - i:::y.7:t. , - , :::'. ..: .:..:i: f ; ' ...'.....•' ' • : ' Casing: li :: . E - . - 0 ...... E CC•ri.Crt:ii, • .:- - " E ...., - 0 0 0 - CC C . 0 C .0 7, .- '- Liner: - E 0 0 C i . . 0 0 0 0 . . (---- ' Drive Shoe-ted E Inside 0 Outside 0 None . Final-h of shoc(s) . I (7) PERFORATIONS/SCREENS: ,.....-- , . . ....---- 0 Perforations Method .- LT Screens Type -- . -- Material . Slot ..-- ..., -- Ttle/pipe ---- , From To size Number' Diameter size Casing Liner' l , . 1 _......-' I 0 0 0 E . ..- - 7 0 . C 0 (8) WELL TESTS: Minimum testing time is 1 hour ..--.--"" Date started .::,. 2 :.'.-- ',1 - Completed Floing . to obondedi Water Well Constructor Certification: (7_1 Pump- O Bailer 0 Air CLATtesian .,.. I certify that the work I performed on I tie construction, alteration. or abandon- Yield gal./min Drawdown Drill stem at ...."-- Time merit of this well is in compliance with Oregon water supply well construction _,.....--'' 1 hr. standards. Materials used and information reported Jbove are true to the best of aty .... knowledge and belief. . , „. _ ,--- .. . , . WWC Number • ' - -• '.• ',-- i-- i Signed '. • - : .. ' . Date i" -./ ' • ' - . _.. Temperature of water -. Artesian Flow Found (bonded) Water Well Constructor Certification: Was a water analysis.dUne? 0 Yes By whom I accept responsibility for the construction, alteration, or abandonment work - performed on this well during the construction dates reported above. All work Did any strata co water not suitable for intended use? 0 Too little performed during this time is in compliance with Oregon water supply well C Salty,4:11 Muddy 0 Odor 0 Colored 0 Other _construction standards. This report is true to the best of my knowledge andbehei. WWC Number Depth'd strata: Signed - . , .,-..-• - , . .--•Date • ' - , ' , ' .. ....... -- ... . . . May 04 04 01:53p Derek Brown & Assoc. (971) 233 -0071 p.4 ., FOR WATER RESOURCES DEPARTMENT USE ONLY Date :Postmarked W ,16 42 31 Date Hand - Delivered OWRD Receipt Date Region Office Rec'd Date Fee Received • Check No. -_ -- _.__ _ START. CARD ' NOTICE OF BEGINNING OF WELL CONSTRUCTION (as required by ORS 537.762) This form must be completed and the original mailed or delivered to the Water Resources Department, 725 Summer Street NE Suite A, Salem OR 97301 -1271 for all new construction, conversion, alteration, deepening and abandonments. This original must be mailed or delivered before work is commenced. A $125 fee shall accompany the original for all new well construction, conversion, and deepenings (make checks payable to the Water Resources Department). In addition, the constructor shall provide a legible copy of this notice to the region office within which the well is being constructed, converted, altered, deepened, or abandoned using one of the following methods: (a) by regular mail no later than three (3) calendar days (72 hours) prior to commencement of work; (b) by hand delivery, during regular office hours before work is commenced; or (c) by FAX before work is commenced. If method (c) is used, a legible copy of the start card shall also be mailed or delivered to the region office no later than the day work is commenced. The Water Resources Commission has authority to impose civil penalties for failure to submit the required S125 fee with the start card,.for failure to submit the $125 fee in a timely manner, and for failure to timely submit start cards. Owner's name and mailing address: Home Phone: ( ) Work ., - Phone: ( ) .�. Type of work: Fee ❑ New Construction No Fee ❑ Alteration (Repair/Recondition) Required: ❑ Conversion' . Required: .• [ .Abandonment Orig. Start ❑ Deepening Orig. Start Card No. Card No. - Proposed Commencement Date: - - Existing or Proposed Well Depth: Diameter: Original Well I.D. Label Number:. Use: 0 Domestic 0 Community (Public System) ❑ industrial ❑ Irrigation . 0 Thermal 0 Injection ❑ Monitoring 0 Other Proposed Well Location: County - Township — Range / ` , - 1 Section Tax Lot - North or South East or West 1/4 1/4 Or Latitude Longitude Street Address of well, if not assigned, nearest address: We have read the back of this form and the information provided is accurate to the best of our knowledge. • OwneriAeent Name y' Bonded Water SiI 1 Monitor Well Constructor Name License No. • Date Signed Company Date Signed OWNER PLEASE NOTE: This is not a water right application. The owner is responsible for obtaining a water right through the Water Resources Department, if required. The Oregon Health Division requires plans to be submitted and approved prior to construction if the well is to be used as a public system. ADDITIONAL,IMPORTANT INFORMATION ON BACK. ' ' • f, ' •' tf•, rirl! . ;"• ;" 6..0,l, Ur.: .. -0 I•:V;... :4- 0....vi A...!..S ,.,..,.. 4b.,J, . . STATE OF OREGON 2 : 07:..'_; .1. ...,.!. ry WATER SUPPLY WELL REPORT ilai :JR 9'; J".;. . WELL I.D. # L IV JP: (as required by ORS 537.765) START CARD # 166607 Instructions. for. completing this report are on the last page of this form. . . (1) LAND OWNER Well Number (9) LOCATION OF WELL by legal description: Name Pf 177`,..t rr CountyWashiminn Latitude Longitude Address 21.r), ' 7.,:J..,7 C77 T,A1 Township IN N or S Range 2 E or W. WM. City 1-3-ILLSBORC) State OR Zip ::-.)-1124.1 Section .7,!5 .' .1/4 rt. 1/4 (2) TYPE OF WORK rIn - Tax Lot — - Lot Block Subdivision 0 New Well E Deepening E Alteration (repair/recondition) :E• Abandonment - Inc ,le, '"5 ':,,1 %'• -—,r3,4" Street Address of Well (or nearest address) , - ,, )1 , Li ■V -±',,`."1::.....:::,,_•,,,,,,,...1,0 f.......-... (3) DRILL METHOD: .., ,..701-N 0.T_EST7t.q ASIT7 1D Rotary Air 0 Rotary Mud 0 Cable 0 Auger (10) STATIC WATER LEVEL: 0 Other ',...- ft. below land surface. Date (4) PROPOSED USE: Artesian pressure lb. per square inch Date - ,0 Domestic E Community 0 Industrial 0 Irrigation (11) WATER BEARING ZONES: . .,-- 0 Thermal 0 Injection D Livestock 0 Other .„-- (5) BORE HOLE CONSTRUCTION: ,-----; Depth at which water was first found ..,--- Special Construction approval 0 Yes IT) No Depth of Completed "' From To Estfiated ' ft. Flow SWL Explosives used El Yes E No Type -• - Amount ' HOLE SE .....----" . ...,...-.., Diameter From To Material From To Sacks or pounds ,..-' ' • _.,_ ..-• ...-- (12) WELL LOG: ' How was seal placed: Method E A 0 B :0 C E D E E Ground Elevation 0 Other Backfill placed from ft. to ft. Material Material From To SWL Gravel placed from ft. to ft. Size of gravel I '3ttP.e.:1 (7 '.. I :,-,. '.=. r: 24 (6) CASING/LINER: . .... ... „,. Diameter From To Gauge Steel Plastic Welded ,Thieaded :Fill (,...i.fe :.-t - tt - Casing: D E . -0 E .,.....-- f77-Ini) ,,:-_,/,---, "tI t.-7-,,.,„..4.-r,i i .4 E 0 . - .,- 0 E 0 0 E ,,, . - Liner: . E 0 0 : , ------ 0 E 0 D _ . Drive Shpetuseci Ei Inside 0 Outside 0 None Final lOcation of shoe(s) (7) PERFORAT1ONS/SCREENS: .....--,„...,- ' I ---- 0 Perforations Method „..0.- . 0 Sci Type Material ' _,.. Slot ., Tele/pipe From To size Number Diamiiter size Casing Liner . 0 0 .., • _ ... 0 0 • - ,..-• - 0 ED - • 0 0 (8) WELL TESTS: Minimum testing time is 1 hour ...----- Date started I; Completed . . .. _. . Flowing (unbonded) Water Well Constructor Certification: El Pump - 0 Bailer 0 Air -D Artesian ...- I certify that the work I performed on the construction. alteration, or abandon- Yield gal/min Drawdown Drill stem at ..,' Time meat of this well is in compliance with Oregon water supply well construction ,-,-- I 1 hr. standards. Materials used and information reported above are true to the best of my knowledge and belief. WWC Number Signed . Date ,-,---' Temperature of water .,--,' Depth Artesian Flow Found (bonded) Water Well Constructor Certification: ., . . Was a water analysis`tione? D Yes By whom I accept responsibility for the construction, alteration, or abandonment work performed on this well dunng the construction dates reported above. All work Did any strata contain water not suitable for intended use? 0 Too little performed during this time is in. compliance with Oregon water supply well 0 Salty/ ICI Muddy E Odor E Colored 0 Other construction standards. This report is true to the best of my knowledge and belief. „....._ Depth of strata: . . .WWC Number Signed ‘-----d.:-•: ._.......... ...--------' Date t"; i ORIGINAL - WATER RESOURCES DEPARTMENT FIRST COPY - CONSTRUCTOR SECOND COPY - CUSTOMER , 'w *t ' FOR, WATERRESOURCES 'DEP'ARTMENT` Date Postmarked W �Dai'e��I3an ;D' lxered�,_.. -. ,4.,. �..��:.,- _��;Fx< .:�;; .;.. ._��:�:`.�:. ���.:, ���. ��OWRD= I2ecei�'t: "��_���<`.,.. .�.. ..�,...•:.,• ^ "; Date"`Re onr0 ce, ec:.d• - .. -• - - - - �7 _, ; ..,•..,., :.�:� -; ,,, Date�Eee :Recelvedn,- „ ,;R�.:.��.:. �,.:.,� =.1 :t+?- 's,,.,r b.`,.,w•, _ , .3�:..,r, am. - ._d t }, t ,.,�. x.., �, - Cry ^.� = `ra< • ” START CA NOTICE OF BEGINNING OF WELL CONSTRUCTION (as required by ORS 537.762) This form must be completed and the original mailed or delivered to the Water Resources Department, 725 Summer Street NE Suite A, Salem OR 97301 -1271 for all new construction, conversion, alteration, deepening and abandonments. This original must be mailed or delivered before work is commenced. A $125 fee shall accompany the original for all new well construction, conversion, and deepenings (make checks payable to the Water Resources Department). In addition, the constructor shall provide a legible copy of this notice to the region office within which the well is being constructed, converted, altered, deepened, or abandoned using one of the following methods: (a) by regular mail no later than three (3) calendar days (72 hours) prior to commencement of work; (b) by hand delivery, during regular office hours before work is commenced; or (c) by FAX before work is commenced. If method (c) is used, a legible copy of the start card shall also be mailed or delivered to the region office no later than the day work is commenced. The Water Resources Commission has authority to impose civil penalties for failure to submit the required $125 fee with the start card, for failure to submit the $125 fee in a timely manner, and for failure to timely submit start cards. Owner's name and mailing address: Home Phone: ( Work' Phone: Type of work: Fee - 0 New Construction No Fee ❑ Alteration (Repair/Recondition) Required: ❑ Conversion Required: lll•A.bandonment Orig. Start 0 Deepening Orig. Start • Card No. Card No. Proposed Commencement Date: � - Existing or Proposed Well Depth: Diameter: , %A:, Original Well I.D. Label Number: Use: - Domestic ❑ C ommunity (Public System) ❑ Industrial ❑ Irrigation ❑ Thermal ❑ Injection 0 Monitoring ❑ Other Proposed Well Location: /.„" / / County Township p '� - Range , r , { Section :. ,_,�� �_ ,., E °�. _ ii f . - .�� _: Tax Lot North or South East or West - 1/4 1/4 Or Latitude Longitude Street Address of well, if not assigned, nearest address: ' t ; V., f � i� 5 .y 4 ,i. J.. _ _ .- ,va,.d"f � ,vt e, _ t. F . : i - • We have read the back of this form and the.-information provided is accurate to the best of our knowledge. • Ar id J Owner /Agent Name Bonded Water` Supply/Monitor�Well Constructor`lame License No. i Date Signed Company Date Signed OWNER PLEASE NOTE: This is not a water right application. The owner is responsible for obtaining a water right through the Water Resources Department, if required. The Oregon Health Division requires plans to be submitted and approved prior to construction if-the well is to be used as a public system. ADDITIONAL IMPORTANT INFORMATION ON BACK. **************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** THIS COPY TO CUSTOMER A. M. JANNSEN WELL DRILLING CO., INC. 21075 SW TUALATIN VALLEY HWY. ALOHA, OR 97006 (503) 649 -5563 INVOICE BILL TO: RUTAN CONSTRUCTION DATE: MAY 22, 2004 4949 SW MEADOWS RD. #400 INVOICE NO. 9603 LAKE OSWEGO, OR 97035 _ WORK ORDER #1559 ABANDON 8" TILE CASED WELL, BONITA & FANNO CREEK RD PROFESSIONAL SERVICES /LABOR FEES $ 300.00 MATERIALS: 34 SKS. CEMENT /BENTONITE 510.00 START CARD FILING & ABANDONMENT REPORT 100 .00 TOTAL INVOICE $ 910.00 1% Finance Charge per month on Past Due Accounts j(ii1e 1 1 6 1 ) / r La \-''' g©&.-„ ; 2004 \'''.\''' U TO 'd 2S:8 VOOZ zZ 6 pW STOS6V920S: xPd A.1ddf1S 71319 Na J.S3m 1 .LO HA MT, RY >S ERVICE INVOICE NO 8600 SW Hillsboro Hwy., Hillsboro, OR 97123 8 5 15 503- 644 -2797 • 503 - 648 -6254 503 -639 -5188 Iti L- • I/�- . is t' -, NAME: f • f �f J 1 ,,', 7 '..-44 7 t "( ADDRESS: ',,1..c.) �1.. `;>' ,F:"/'- -'?;.%6'..vi�i�.J , -' i _- w. CI :A. / `. - -2" ,tZ-\; / STATE: -- <... ZIP: ( "77/2 V ~ HOME: .74 Y -; : WORK: CELL: t ,--- --- ; , , ' 1 s i . JOB SITE: : _..i'". J , •' i,,!__ r - r"', .r'J s`< .2; a , /' °L P.O. #: PAID BY CHARGE 7 3 CHECK ❑ 1 CASH ❑ CREDIT CARD ❑ '.. i . DATE •- -2 ("3 "•- t) g, DRIVER '_•N.,,( ,s' .liar/ ! AMOUNT PUMP SEPTIC TANK - __ ) {� ❑ INSPECTION FEE • i ; ❑ SERVICE CALL 1 ❑ LABOR, LOCATING, DIGGING, BACKFILL I J l' /, /' , . . i i 1'__ ° ' I/A ) ,'-i6 TOTAL $ ,2,..5 elf — _ MIS IS NOT SEPTIC: J YSTEM INSPECTION REPORT — >11 - -- ', ref if K - TYPE OF TANK: STEEL ❑ CONCRETE ❑ PLASTIC ❑ HOMEMADE ❑ , I HORIZONTAL ❑ VERTICAL ❑ RECTANGLE ❑ ❑ OTHER SIZE OF TANK: 350 ❑ 500 ❑ 750 0 * 1000 CI 1250 ❑ 1500 ❑ 2000 ❑ 3000 ❑ LID LOCATION: INLET ❑ OUTLET ❑ \ /MIDDLE ❑ ENTIRE TOP ❑ TANK CONDITION: GOOD ❑ FAIR ❑ POOR ❑ f a �� ? , FITTINGS: BAFFLES ❑ CONCRETE / I CAST IRON ❑ PLASTIC ❑ 0 (� / {- NEEDS NEW LID? YES ❑ SIZE \ - GROUND COVER OVER TANK / . 1 / COMMENTS ON CONDITION OF DRAINFIELD - ETC. / ` < ✓// C, s . , / � _, ==� fi , ') .i ,; ..y _ - - r �I /V'Y '4 ,./ Ali( .A -' . S IGNED BY DATE , "• � " 1. { • Aloha Sanitary Service Invoice 8600 SW Hillsboro Hwy Hillsboro, OR 97123 DATE INVOICE # 5/27/2004 8515 BILL TO Rutan Construction Co. Q 21515 NW Cherry Ln Hillsboro, OR 97124 -5605 P.O. NO. TERMS JOB DATE JOB SITE Net 30 5/20/2004 Bonita Town Homes QUANTITY DESCRIPTION RATE AMOUNT Septic Cleaning (Tank Demo) 250.00 250.00 Job #: 040309 • • f Sri j I SUN -;4114 L i iwTAN O C Total $250.00