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Permit I CITY OF TIGARD SEWER CONNECTION PERMIT DEVELOPMENT SERVICES PERMIT #: SWR2005 -00318 9.J � . 13125 SW Hall Blvd., Tigard, O 97223 503 - 639 -4171 DATE ISSUED: 11/8/2005 PARCEL: 2S110BC -00900 SITE ADDRESS: 12475 SW BULL MOUNTAIN RD ZONING: R -1 SUBDIVISION: LOT: JURISDICTION: TIG Project Description: 2.5 EDU increase. TENANT NAME: CWS NO: FIXTURE UNITS: CLASS OF WORK: ALT DWELLING UNITS: 2.5 TYPE OF USE: COM NO. OF BUILDINGS: INSTALL TYPE: BUSWR IMPERV SURFACE: Owner: FEES TIGARD WATER DEPT. 8777 SW BURNHAM ST Description Date Amount TIGARD, OR 97223 [SWUSA] Sewer Connection Fee 11/8/2005 $6,500.00 Total $6,500.00 Phone: 639 - 4171 395 Contractor: HAMPTON PLUMBING CO. 411 S COLLEGE ST NEWBERG, OR 97132 REQUIRED ITEMS AND REPORTS Phone: 503 -538 -5629 Reg #: LIC 160927 PLM 36 -102PB 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 or 1- 800 - 332 -2344. Issued by: 4,1_,,,-,,, ,,,":"&,. Permittee Signature: el-1. . Ce-4-11 c - - 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. Accumulative Sewer Tally Parcel # 1511`0BC -00506 Tenant Name:. Tigard ASR 2 Well Hous ,,, y , ,..,, ,,,, This SWR;42005 -00318 . , Site Adt"ress ;2'475 SW Bull Mountain R ' �„ e 4 `?'" ' . This PLM# F O05 -00506 , , 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 ,x 0 0 0 0 Bath - Tub /Shower 4 '�` 0 5 u 0 0 0 0 - Jacuzzi/Whirlpool 4 l .: 0 0 0 0 0 G,. Car Wash - Each Stall 6 0 0 0 0 0 - Drive through 16 0 0 0 0 0 Cuspidor/Water Aspirator 1 x V 0 0 0 0 0 Dishwasher - Commercial 4 0 0 0 0 0 - Domestic 2 0 0 S 0 0 0 Drinking Fountain 1 0 0 0 0 0 Eye Wash 1 0 0 1 1 1 1 Floor Drain /Sink - 2 inch 2 0 -, ' 0 0 0 0 - 3 inch 5 0 0 0 0 0 - 4 inch 6 0 0 6 36 6 36 - 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) 42 0 0 0 0 0 Ice Machine /Refrigerator Drain 1 0 0 0 0 0 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 2 0 0 0 0 - Bradley 5 0 0 0 0 0 - Commercial 3 0 0 1 3 1 3 - Service 3 0 0 0 0 0 Swimming Pool Filter 1 0 s�:' 0 0 0 0 Washer Clothes 6 0 01'. 0 0 0 0 Water Extractor 6 0 0 0 0 0 Water Closet - Toilet 6 0 0 0 0 0 Urinal 6 0 0 0 0 0 Previous EDU Count it r 0 0 Capped EDU Credit n � ', 0 TOTALS 0 0 0 0 8 40 8 40 Current Fixture Value 40 divided by 16 = 2.5 Current EDU 1 EDU = $ 2.600 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change 40 divided by 16 = 2.5 over (under) $ 6,500.00 Enter EDU Change Here 2.5 Notes: Authorized Name /Signature ' K alThtter ; :; Date ` ' Building Division Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges. i:\Building\Sewer Tally \SewerTallySheet.xls 7/1/05 CITY OF TIGARD Journal Entry Form JE # 417 G/L # 4 JE Date: 11/7/2005 Description: City of Tigard Sewer Permit ASR Well - 2 Month Ending: 10/31/05 Reviewed By: Entered By: pah Date Entered: Debit( +) Additional Ln# Account # Credit( -) Amount Information Trn# 1 530 - 0000 - 101000 - 6,500.00 SWR Permit 2005- 00318/ASR Well -2 2 530 - 6270 - 755515 + 6,500.00 SWR Permit 2005- 003181ASR Well -2 3 500 - 0000 - 101000 + 6,500.00 SWR Permit 2005 -00318 /ASR Well -2 4 500 - 0000 - 207000 - 6,500.00 SWR Permit 2005- 00318 /ASR Well -2 5 6 7 8 9 10 11 + 13,000.00 12 - 13,000.00 13 = 0.00 14 15 16 20 21 22 23 24 25 26 27 28 29 I: \FIN \Financial Operations \EXCEL \JOURNALS \05 -06 FY\[2005- 10.xls]O4JE #417 30_ COPY 11/7/2005 Fees Associated With 3:12:45PM Case #: SWR2005 -00318 City of Tigard Fee Start End Revenue Created Type Date Date Dept Description Account Number By Date Amount Due PRMT 1/1/1990 12/31/2005 [SWUSA] Sewer Connection Fee 500- 0000 - 207000 BB 10/7/2005 6,500.00 6,500.00 , Total: $6,500.00 Sao 2 77 - Xa�Bv Dock Page 1 of 1 CaseFees..rpt Accumulative Sewer Tally Parcel # 1S110BC -00506 • Tenant Name: Tigard ASR 2 Well House This SWR# 2005- 00318 Site Address: 12475 SW Bull Mountain R. This PLM# 2005 -00506 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 0 0 0 Eye Wash 1 0 0 1 1 1 1 Floor Drain /Sink - 2 inch 2 0 0 0 0 0 - 3 inch 5 0 0 0 0 0 - 4 inch 6 0 0 6 36 6 36 - 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) 42 0 0 0 0 0 Ice Machine /Refrigerator Drain 1 0 0 0 0 0 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 0 0 0 - Bradley 5 0 0 0 0 0 - Commercial 3 0 0 1 3 1 3 - Service 3 0 0 0 0 0 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 0 0 0 Urinal 6 0 0 0 0 0 Previous EDU Count 0 0 Capped EDU Credit 0 TOTALS 0 0 0 0 8 40 8 40 Current Fixture Value 40 divided by 16 = 2.5 Current EDU 1 EDU = $ 2,600 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change 40 divided by 16 = 2.5 over (under) $ 6,500.00 Enter EDU Change Here 2.5 Notes: Authorized Name /Signature:? Barbara Butler Date: 10/7/2005 Building Division Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges. is \Building \Sewer Tally \SewerTallySheet.xls 7/1/05