Permit CITY OF TIGARD
SEWER CONNECTION PERMIT
�,,�11I1 DEVELOPMENT SERVICES DATE IS 12/2/03 R2003 -00386
h--- 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS; 12350 SW KELLY LN PARCEL: 2S103CC -08200
SUBDIVISION: WHISTLER'S WALK ZONING: R - 4.5
BLOCK: LOT: 029 JURISDICTION: TIG
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 permit for new SF dwelling.
Owner:
FEES
DON MORISSETTE HOMES
4230 GALEWOOD ST Description Date Amount
STE 100 [SWUSA] Swr Connect 12/2/03 $2,400.00
LAKE OSWEGO, OR 97035 [SWUSA] Swr Connect 12/2/03 $0.00
Phone: 503- 387 -7538 [ SWINSP] Swr Inspect 12/2/03 $35.00
[SWINSP] Swr Inspect 12/2/03 $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) 39 -4175 by 7:00 P.M. for an inspection needed the next business day