Permit . CITY OF TIGARD SEWER CONNECTION PERMIT
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PERMIT #: SWR2004 -00005
DEVELOPMENT SERVICES DATE ISSUED: 1/14/04
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171
SITE ADDRESS; 13855 SW PACIFIC HY PARCEL: 2S103DD -00900
W
SUBDIVISION: ZONING: C -G
BLOCK: LOT: JURISDICTION: TIG
• TENANT NAME: COMMUNITY OF CHRIST CHURCH
USA NO: FIXTURE UNITS: 5
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .3 EDU increase
Owner: FEES
COMMUNITY OF CHRIST CHURCH
5321 WINDSOR TERRACE Description Date Amount
WEST LINN, OR 97068 [SWUSA] Swr Connect 1/14/04 $720.00
[SWUSA] Swr Connect 1/14/04 $0.00
Phone:
Total $720.00
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" Perm
Issued by: P ermittee Signature: / ��
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally Parcel # 2S103DD - 00900
Tenant Name Con(rnunity of Christ Church This SWRt 2004 -00005
Site Address: 13855 SW Pacific Hwy. This PLM# 2004 -00006
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 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
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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 Drr, 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) 48 0 0 0 0 0
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Ice Machine /Refrigerator Drain 1 0 0 0 0 • 0
Oil Sep (Gas Station) 6 0 0 0 , 0 0
Rec. 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 0 0 . 0
- Bradley 5 0 0 0 0. 0
- Commercial 3 0 0 2 6 2 6
- Service 3 0 0 0 0 0
Swimming Pool Filter 1 0 1 1 0 -1 -1
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 1 1 2 6 1 5
Current Fixture Value 5 divided by 16 = 0.3 Current EDU 1 EDU = $ 2,400
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 5 divided by 16 = 0.3 over (under) $ 720.00
Enter EDU Change Here 0.3
Notes: ,
Signature: d y� p. , 7 f s ;fi Date: / —j 5.-67 y /
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
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