Permit , 11
CITY TIGARD SEWER CONNECTION PERMIT
I � DEVELOPMENT SERVICES PERMIT #: SWR2003 -00395
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 1/22/04
SITE ADDRESS; 11550 SW GALLO AVE PARCEL: 1 S134DC 11200
SUBDIVISION: CASCADIAN PLACE ZONING: R - 4.5
BLOCK: LOT: 001 JURISDICTION: TIC
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 residence.
Owner:
FEES
KEYSTONE DEVELOPMENT INC Description Date Amount
PO BOX 476
LAKE OSWEGO, OR 97034 [SWUSA] Swr Connect 1/22/04 $2,400.00
[SWUSA] Swr Connect 1/22/04 $0.00
Phone: 503 -635 -4736 [ SWINSP] Swr Inspect 1/22/04 $35.00
[SWINSP] Swr Inspect 1/22/04 $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" Perm
Issued by: Permittee Signature: •
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the • siness day