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Permit • CITY T I GA R D SEWER CONNECTION PERMIT A. PERMIT #: SWR2004 -00225 i` D EVELOPMENT SERVICES _ . �I- 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 8/20/2004 SITE ADDRESS; 11535 SW PACIFIC HWY PARCEL: 1S136AD -04000 SUBDIVISION: VILLA RIDGE ZONING: C - BLOCK: LOT: 007 JURISDICTION: TIG TENANT NAME: HALAL MEAT & MEDITERRIAN USA NO: FIXTURE UNITS: CLASS OF WORK: ALT DWELLING UNITS: TYPE OF USE: COM NO. OF BUILDINGS: INSTALL TYPE: BUSWR IMPERV SURFACE: Remarks: .4 EDU increase. Owner: FEES SMITH, EDITA M 833 NW 170TH DR Description Date Amount BEAVERTON, OR 97006 [SWUSA] Swr Connectic 8/20/2004 $1,000.00 [SWUSA] Swr Connectic 8/20/2004 $0.00 Phone: Total $1,000.00 Contractor: 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" 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. Issued by: Permittee Signature: A Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day Accumulative Sewer Tally Parcel # T.:0004040404-4 �naar , ii�at �° a `�,: .'- ,` n fi ,' This SWRk 1 1 ? . ® Sj k+` e '`tt . 4 �i,a Vi;,i ' s, ,.. '... This PLM Z , 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 iix, 4, 0 0 5,,::.,„5,,,,:i%., 0 0 0 Bath - Tub /Shower 4 0 x, 0 1, 0 0 0 - Jacuzzi /Whirlpool 4 „ , '' 0 0 4,;„ 0 0 0 Car Wash - Each Stall 6 ._ 0 .,, 0 .. 0 0 0 - Drive through 16 ;y , ' y 4,. 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 I,,. , w 0 r,„ .:' 0 0 0 0 Eye Wash y 1 � �,1":° 0 .A. i. ,; 0 s s 0 0 0 Floor Drain /Sink - 2 inch 2 l .,; 0 0 2 1 2 3 inch 5 :, 0 0, '': 0 0 0 6 � 0 3 - IC mow: - 4 inch , � ,« , 0 �� ,y���i„ 0 0 0 - Car Wash Drr 6 i `a 0 i u 0 eta> y, 0 0 0 Garbage Disposal - Domestic (to 3/4 HP) 16 " : 0 fr "„ • 64 , .. 0 4a •. a 0 a rStaiWA - Commercial (to 5 HP) 32 � , 0 0 .> a 0 0 0 - Industrial (over 5 HP) 48 Y t om : 0 :,:-".'..0:6:6,:.!! 0 v ;v 0 0 0 Ice Machine /Refrigerator Drain 1 ` •.s 0 a y a a a Oil Sep (Gas Station) 6 i 0 0 0 Rec. Vehicle Dump station 16€ ' 0 0 ffi, ; 0 0 0 Shower - Gang (per head) 1 k s 0 :r 0 x' 0 0 0 - Stall 2 .\ :; ?x 0 , a:n~ 0 f t 0 0 0 Sink - Bar /Lavatory 2 . °-" 0 7g 0 >` t* - Bradley 5 ..; ` 0 0 , 0 0 0 Commercial 3 f '''''''''t.'`.74 0 ° ' " 0 ~' ''` to 0 0 0 - Service 3yy s 0x 0 „ 0 0 0 �i .;�h 3 Swimming Pool Filter I -n 1 , 0 0 0 0 0 Washer - Clothes 6 0 ,1 0 killl 0 0 0 Water Extractor 6 , 0 5 , r ` i = 0 2 0 0 0 . `;.ter' 0 k 0 s S. 0 0 0 Water Closet - Toilet 6 r N Urinal 6 ' ,.. 0 0 'Y x` 0 0 0 Previous EDU Count 0 0 Capped EDU Credit ''r x . 0 TOTALS 0 0 0 0 3 6 3 6 Current Fixture Value 6 divided by 16 = 0.4 Current EDU 1 EDU = $ 2,500 Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU Change 6 divided by 16 = 0.4 over (under) $ 1,000.00 Enter EDU Change Here ©, ., Notes: Adds to PLM2004 -00303 Signature: AP ` _, _i,_ Date: • 30 A 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 11/19/03