Permit .
74 4 CITY OF TIGARD SEWER CONNECTION PERMIT
: COMMUNITY DEVELOPMENT PERMIT #: SWR2008 - 00144
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 10/15/2008
PARCEL: 1 S135DD -03301
SITE ADDRESS: 11945 SW PACIFIC HWY 202 ZONING: C -
SUBDIVISION: TIGARD PLAZA LOT: 002 JURISDICTION: TIG
PROJECT: LUCKY DELI
Project Description: .1 EDU increase
TENANT NAME: LUCKY DELI
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0.1
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner: FEES
TIGARD PROPERTIES INC
2106 SE OCHOCO ST Description Date Amount
MILWAUKIE, OR 97222
[SWUSA] Sewer Connection Fee 10/15/200€ $310.00
Phone: Total $310.00
Contractor:
Contact #: REQUIRED ITEMS AND REPORTS
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.
j Issue by: / P ermittee Signatur ( !
Call 503.639.4175 by 7:00 a.m. for an inspection • at b fines, day.
This permit card shall be kept in a conspicuous place on the job site • it co pletion of the project.
Approved plans are required on the job site at the time of each inspection.
{ Accumulative Sewer Tally, Parcel # 1 S135DD -03301
Tenant Name: LUCKY DELI This SWR# SWR2008 - 00144
Site Address: 11945 SW PACIFIC HWY This PLM# PLM2008 - 00404
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
Baptiscry/Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
- Jacuzzi /Whirlpool 4 0 0 0 0 0
Car Wash - Each Stall 6 0 0 0 0 0
- Drive through 16 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 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 0 0 0
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 HP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 0 0 0 0
Rcc. Vehicle Dump station 16 0 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink - Bar /Lavatory 2 0 0 1 2 1 2
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 0
TOTALS 0 0 _ 0 0 1 2 1 2
Current Fixture Value 2 divided by 16 = 0.1 Current EDU 1 EDU = $ 3,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 2 divided by 16 = 0.1 over (under) $ 310.00
Enter EDU Change Here 0.1
Notes:
Authorized Name /Signature: BRANDEN TAGGART Date: 10/15/2008
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 \Sewerl'allySheet- 3100.xls 06 /19/08