Permit c I
CITY F TI CARD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2005 - 00071
DATE ISSUED: 4/7/2005
13125 SW Hall Blvd., Tigard, OR 97223 503- 639 -4171 PARCEL: 2S112CD RM002
SITE ADDRESS; 07925 SW CAROL ANN CT ZONING: R -12
SUBDIVISION: REBECCA MEADOWS LOT: 002 JURISDICTION: TIG
Project Description: Sewer connection
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner: FEES
KEYSTONE DEVELOPMENT INC
PO BOX 476 Description Date Amount
LAKE OSWEGO, OR 97034
[SWUSA] Swr Connection Fee 4/7/2005 $2,500.00
[SWINSP] Sewer Inspection Fee 4/7/2005 $35.00
Phone: 503- 635 -4736 Total $2,535.00
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 obtain copies of these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issued by: f1 � Permittee Signature: j 6
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that usineys day.
This permit card shall be kept in a conspicuous place on the job site un il of the project.
Approved plans are required on the job site at the time of each inspection.