Permit , •
CITY TIGARD SEWER CONNECTION PERMIT
r DEVELOPMENT SERVICES PERMIT #: SWR2003 -00366
cJ II 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 9/25/03
SITE ADDRESS; 12442 SW SCHOLLS FERRY RD 100 PARCEL: 1S134BC-00401
SUBDIVISION: ZONING: C -N
BLOCK: LOT: JURISDICTION: TIG
TENANT NAME: PROVIDENCE HEALTH SYSTEM
USA NO: FIXTURE UNITS: 6
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .4 EDU increase, previous fixture unit were 210, this permit adds 6 fixture units for a new total 216
units.
Owner:
FEES
SISTERS OF PROVIDENCE IN OR
BY STEVE FOSTER Description Date Amount
PO BOX 13993 [SWUSA] Swr Connect 9/25/03 $960.00
PORTLAND, OR 97213 [SWUSA] Swr Connect 9/25/03 $0.00
Phone:
Total $960.00
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
Iss by: Permittee Signature: y
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed the next business day