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Permit N ., CITY OF TIGARD PLUMBING PERMIT COMMUNITY DEVELOPMENT Permit #: PLM2012 00020 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 01/26/2012 Parcel: 2S 111 BA00803 Jurisdiction: Tigard Site address: 9960 SW MCDONALD ST Project: ENGEL Subdivision: TIGARDVILLE HEIGHTS Lot: 24 Project Description: Connecting existing home to sewer with drain reversal. Contractor: JACK HOWK PLUMBING /RESCUE ROOTER Owner: ENGEL, JOHN B P.O. BOX 2830 9960 SW MCDONALD ST CLACKAMAS, OR 97015 TIGARD, OR 97224 - PHONE: 503 - 235 -8784 PHONE. FAX: 503 - 491 -2932 FEES Quantity Description Date Amount 40 If Sewer Service 01/26/2012 $62.54 Specifics: 25 Misc Other Fee 01/26/2012 $25.02 1 12% State Surcharge - 01/26/2012 $10.51 Type of Use: SF Plumbing Class of Work: ALT Type of Const: Occupancy Grp: Stories: Total $98.07 Required Items and Reports (Conditions) 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 the 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 -0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1.800.332.2344. Issued By: �� Permittee Signature: Call 503.639.4175 by 7:00 a.m. for the next available inspection date. 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. Plumbing Permit Application Building Fixtures ��� � � 1 F OR o F Y � r�O � r ''� Received �� - �.,� City of Tigard r n 13125 SW Hall Blvd., Tigard, OR 9233 �. `��, Date/By • / ryto ��. Permit No.. pu 4.1. Plan Review - �`arr� Phone: 503.639.4171 Fax: 503.598.1960 N Other Permit No.: Date /By: .. �Y' . k T IG A RD Inspection Line: 503.639.4175 www.tigard-or.gov r^� 1 l I �1Sl ' � \ 7� - Supplemental Information Date ea y y' Rids Page 2 for Notfied /Metho . EE �> �...: ,..,, �- .. ,� -...:a ....,. it - M AI E,,, „�_, >�.�r.: AA �.��� ❑ New construction ❑ Dion For special information use checklist. Description Qty. Ea. Total Addition /alteration /replacement ❑ Other: New 1 - 2 - family dwellings (includes 100 ft. for each utility connection) '' ; ^;:` CNr. ! :. , '„ . :''I C� OFhb'sgRIjCTIo ii = ;`nZrt"•� SFR 1 bath ..._ a„. •..,� -.,..: �...�,;;�... c':�^ ,,.,,.....nF.,..= .:�fav,�.a >�xi , :-, �,� .,, ,.,, . 'uw' s „ ` � a,.. - O 312.70 IZI- and 2- family dwelling ❑ Commercial /industrial SFR (2) bath . 437.78 El Accessory building 111 Multi-family SFR (3) bath 500.32 ❑ Master builder Each additional bath /kitchen 25.02 Fire sprinkler ( sq. ft.) Paoe 2 ;: °F - Wife fA : V'j- QBSJTE I N RM EOAT ND `LOCH fti f ; ,;- >.;c.- , r , :N:.. v : ;,=' ; -_'P..:.z v;, ° ,,4 . , : . , - _ �.., . . .n,-''.._ : >. ,:. Site u t i lities: Job site address: �� /V �jp City /State /ZIP: (� sr Catch basin or area drain 18.76 It_y % L V Drywell, leach line, or trench drain 18.76 � Footing drain (no. linear ft.: ) Page 2 Suite /bldg. /apt. no.: I Project name: (.9/ v I Ci` Manufactured home utilities 50.03 Cross street /directions to job site: Manholes 18.76 Rain drain connector 18.76 Sanitary sewer (no. linear ft.: _) d Page 2 .5 Storm sewer (no. linear ft.: _ ) Page 2 Water service (no. linear ft.: _ ) Page 2 Subdivision: I Lot no.: Fixture or item: Tax map /parcel no.: Backflow preventer 31.27 '�` "` �,,. Backwat valve 2:5] , gy ;,. j;: WO12Kx'��.s�Y - F J �� 4'/ MY 60P7- j N Clothes washer � 25.02 n /J�� Dishwasher • 25.02 ‘:01 � tiRCIL4J J / 4 /V 'a v V , Drinking fountain 25.02 Ejectors /sump 25.02 R .:,3i, ,, -,. NER ° , .3 - n ;u .: Poi � Expansion tank 12.51 • Name: Fixture /sewer cap 25.02 ` - 0 x 15 ( /�� Floor drain floor sink/hub 25.02 :; �' � Address 6 r �Y Garbage disposal 25.02 City /State /ZIP: 7 7 i f 4 i Q � � / 1/ Hose bib 25.02 . Phone: ( ` r bCY Z 2 Fax: ( ) Ice maker 12.51 %>�.�•�'• -•` • �c�;' "``� ":�..� a •<_,�- �" �,�:: �",i�. :':', r .> �. z•; a ; ? ?.a>:., ^. e.:mn,:�..�,:,;«pe,o ., ^,,p „'s i - 4 P6614','• . y'_ ::C ON: ' -` w ~ interce tor/ rease trap . -,rt a AC.,, S(�N e: p g p 25.02 • Business name: ARS dba JACK HOWK/RESCUEROOTER Medical gas (value: $ ) Page 2 Contact name: JOYCE DENNIS Primer 12.51 Roof drain (commercial) 12.51 Address: P.O. BOX 2830 ' Sink/basin/lavatory 25.02 City /State /ZIP: CLACKAMAS, OR 97015 Solar units (potable water) 62.54 Phone: (503) 850 -3100 Fax: : (503) 491 -2932 Tub /shower /shower pan - 12.51 E -mail: JDENNIS @ARS,COM Urinal 25.02 � y': •.ce.a`i ..; �k> �, :3rt ��, ,., „., -, 1 "T,:':" .. ��;E 31 .�:.;�• y-.: �e:,, ,,, ° °.; ;. ; ,, T ° :��e , ,°:, ,;, :E . � j 3 t Water closet 25.02 i '�"� '"�''1°�� T- `al Water heater 37.52 Business name: ARS dba JACK HOWK/RESCUE ROOTER Water i In DWV 56.29 pp g/ 0 Address: P.O. BOX 2830 Other: 2A) g5 25.02 City /State /ZIP: CLACKAMAS, OR 97015 Subtotal Phone: (503) 850 -3100 Fax: (503) 491 -2932 Minimum permit fee: $72.50 CCB Lie.: 127325 Plum ' g Lic. no.: 34-168PB Plan review (25% of permit fee) State surcharge -(12% of permit fee) / ., r I Authorized signature: TOTAL.PERMIT 2 Print name: JOYCE DENNIS Datea7 / This permit application expires if a permit is not obtaine wit • :!'1,1 ,4Pr after it has been accepted as complete. i & P1154gt )94 *Fee methodology set by Tri- County Building Industry .: ,�..•-:^ I.\Bmlding \Permits\KMU- PermltA '10 440- 4616T(10/02 'OM/W � O t gU 1 Plumbing Permit Application - City of Tigard , Page 2 - Supplemental Information Fee Schedule: Residential Fire Su iression Systems: x� wows '�`l%..,,,.., k e.;.g . ^� ?3 ' S:^ . g>,fFw. : t£• 1 -. � � .� ';ups. °r �>r -� ,QI3' -t� _C ;I'otal . r ���:' SI Ati1E f - =:x ,,: rA �x,.. _�,, �.r,� ,� �.��..s;.�. �. � , , a�e�F�o'ota .e � ...Perll>Fe ■ Footing drain - 1' 100' 50.03 0 to 2,000 $121.90 Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69 3,601 to 7,200 $233.20 a Sewer - 1st 100' 62.54 7,201 and greater $327.54 • Sewer - each additional 100' 37.52 Water Service - 1st 100' 62.54 Medical Ga • s as Systems: Water Service -each additional 100' 37.52 .' x . "� �. ".. e",', ,? "�:y ci::'-`+�»'„ r,' Y.3n ':?.' l essitr.-" e ae <:;;, '' r.M • Storm & Rain Drain - 1st 100' 62.54 ?fi- <d l ilt4lll =` - `` ,` $1.00 to $5,000.00 Minimum fee $72.50 Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for irdit r =T "° r a"` '� ` F ' j = s "1611W each additional $100.00 or fraction thereof, to -- I) " PTO S:- �r Fees, ` � and including $10,000.00 - �1' � ;l?'� « ..��T.,. -��,�, =� 'de's',,:- ����c a� ��;`�a`��r�< Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to (minimum charge - 1/2 hour) and including $25,000.00. Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to Reinspection Fees 90.00/hr and including $50,000.00. Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for (minimum charge- 1/2 hour) each additional $100.00 or fraction thereof. Subtotal: Commercial Fixture Work: Are you capping, or replacing fixtures? '' - 2 R "a R ,` f k s q �° . r g� xtures If "yes", sU:��T .�. �.::- ,. �:.- ,;FS��9 please indicate work performed by fixture. Failure to a�g sIO]lt <� Plan review is required for any of the following. accurately report fixtures could result in increased sewer fees Please check all that apply. 'u:XFr .rie .:",'•s'_', - "` - -° " k �,,` `d;:.s;r ?:u�a k §S " - "r n lliS off:, -,e O'sa:sZ Any new commercial building with water service 2" and :,�- ,�,� Q, u- ar, t�. ty. by ;; (Eizt`u�e }��'f;�lkerformyed � ❑ ,�,�, „yP -.,` = ��r�,,� ;y ��; ; ��`t� r < ,;: ; ��,� .,, �� r• greater, except systems designed and stamped ed b -k, -. n ? .A1. ,. ':_ r i 1r:1 vio'ns� ,Capped Added Faison g P by licensed engineer. Baptistry/Font Bath Tub /Shower ❑ New exterior plumbing site utilities for any complex structure Jacuzzi /Whirlpool • as defined in OAR918- 780 -0040. Car Wash Each Stall ❑ Medical gas and vacuum systems for health care facilities. Drive Thru El Any multipurpose fire sprinkler system. Cuspidor /Water Aspirator ❑ Any complex structure as defined in OAR918- 780 -0040. Dishwasher - Commercial Domestic Submit 2 sets of plans with any of the above. Drinking Fountain • Eye Wash wv ,, ntit , Floor Drain /sink 2" 3 >, ❑ Isometric or riser diagram is required for new buildings that meet the qualifications above. Car Wash Drain Garbage - Domestic • Disposal - Commercial - Industrial Comments regarding fixture work: Ice Mach. /Refrig. Drains Oil Separator (Gas Station) • Rec. Vehicle Dump Station Shower -Gang -Stall Sink - Bar/Lavatory - Bradley - Commercial *Note: If the fixture work under this permit results in an - Service increase of sewer EDUs, a sewer permit will be issued and Swimming Pool Filter P Washer - Clothes fees assessed for the sewer increase must be paid before the Water Extractor • plumbing permit can be issued. Water Closet - Toilet Urinal Other Fixtures: • • http : / /www.tigard - or.gov /city_hall/ departments /cd /docs /PLMF- PermitApi2doc ' General Ledger Journal Entry Proof List - • � • User: amyl Printed: 1/26/2012 - 4:38 PM r< Batch: 00003.01.2012 =zT I G h f.' Account Number Account Description Debit Amount Credit Amount Line Description System Reference Project Management Journal Entry: 371 -07 -2012 Journal Entry Date: 01/26/2012 230 - 0000 -12103 Accts Receivable - Reimb. Dist 35.00 0.00 Inspection Fee - Engel Sewer 230- 0000 -23300 Deferred Revenue 0.00 35.00 Engel Sewer Loan 500 -0000 -12102 Accounts Receivable - CWS 4.500.00 0.00 Connection Fee - Engel Sewet 500 -0000 -12103 Accts Receivable - Reimb. Dist 14,232.00 0.00 Reimbursement Fee - Engel S. 500- 0000 -23300 Deferred Revenue 0.00 18,732,00 Engel Sewer Loan Journal Entry Totals 18,767.00 18.767.00 Journal Entry Balance 0.00 Report Totals: 18,767.00 18,767.00 0.00 /° // 2 / — DO -O — G 0 // GL- Journal Entry Proof List 11/26/2012 - 4:38 PM) Page 1 FEB- 14- 2012(TUE) 15:03 AR5 /JackHouk /RescueRooter (FAX)503 491 2932 P.003/003 WORK ORDER 19133 P Order Date: 1/31/2012 environmental Required Date: Work Date: 2/1/2012 Ordered by: Chuck Howd Location: Company: Jack Howk Rescue Rooter 9960 SW McDonald Tigard. Or Phone: Site Phone: 503- 339 -4683 • Job #: PO #: Site Contact: Aurelio ..SERVICE'DESCRIPTION;' Prevailing Wage: ❑ YES [] NO Vacuum out approx.. 700 gallons of septic from tank and transport to PPV for disposal. pi 1"1 )00. - ©vo ,o iNOlEkto Take 100' of 4" green hose to reach tank .. * ) , ( 1" Operator: Mark Webb • stertTrsv i 1p/ "° , obi fc�.d m' pn , _ nah,Job , "m pm Finsh`offaoadin9,3 "m /pm lStop;Tilvel "'n /pm Laborer Eric Young ti ti : m t.,. �r,���:•:�! "m '"SSR,z -- s.,rn�; 4m/pro L„ ^• >.,,eh.:. "m Sta rivelw J4 " ° f ." ,Jo y fot7.36 pm i Fiiiiif ob / - / m l • a of rtrii r i; / ei Troval;)� / p Laborer: Asa ty7ravehr? /pm .Star iki ; "m /pm F1119hCtOb' me /pm Fles 'oftilo "m / Y8 "nl _ p m • Disposal Site: PPV INC Truck / Equip #: • P -07 Manifest # for Disposal: Gal one USDOT Waste Description (proper shipping name, hazard class, and ID No. Type Quantity To_ Not USDOT regulated Signature: Signed by: Signature above acknowledges approval of all work completed as stated on this work order. If you would like a copy emailed or faxed to you, please provide contact information. Contact info: _ 4927 NW Front Ave., Portland, OR 97210 * phone: 503.261.9800 * fax: 503.261.9900 * toll free: 888.272.8644 www.BravoEnvironmental.com • FEB- 14- 2012(TUE) 15:03 RR5 /JackHouk /RescueRooter (FRX)503 491 2932 P.002/003 • • � SEPTIC TANK DECOMMISSION (ABANDONMENT) For Onsite Sewage Disposal System Washington County Department of Health & Human Services rl^ , Environmental Health ° 14 155 North First Avenue, MS 5, Suite 160 • Hillsboro, Oregon 97124-3072 Telephone: (503) 846 -8722 Please return completed form to Washington County Department of Health & Human Services Envi on gorel He lth 1. _ ownship Range Section Tax Lot ft (s) 2. kJ-64J . Printed Name of Property Owner 3. The septic tank located at 9m (5 A) / ii 40 �,* Address City _ Slate Zip Code , Was pumped of sludge on: ti • Date: 4936 i /o7D /a? • By Licensed Operator. � ail// V i A' +�f : • • . asbackfilied with sand or clean bank run gravel AFTER being plimpod f sludge on: Date: ?•^l0 Signature of Operator. • Oregon Mrninlstrativo Rules 340 Oocornmissloning of. Systems 1) The owner shall decommission a system when: a) A sewerage system becomes available and the building sewer has been connected thereto; or • b) The source of sewage has boon permanently eliminated: • • 2) Procedures for Decommissioning: a) The. tank(s), cesspool or seepage pit shall be pumped by a licensed sewage disposal service to remove all seepage; • • b) The tank(s), cesspool or seepage pit shall be filled with reject sand, bar run gravel or other material approved by tho Agent, or the container shall be removed and properly disposed. The septic tank at the address above has been decommissioned in accordance with Oregon Administrative Rules. • O Signature of Properly Owner: r r / • • • • • WCDHHS EH Revised April 2007 i