Permit CITY OF TIGARD SEWER CONNECTION PERMIT
111 g COMMUNITY DEVELOPMENT Permit#: SWR2015-00110
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 09/14/2015
Parcel: 1 S133AD16200
Jurisdiction: Tigard
Site address: 12700 SW NORTH DAKOTA ST 180
Project: Straight Up Chiropratic Subdivision: 1995-073 PARTITION PLAT Lot: 3
Project Description: .25 EDU increase
Contractor: Owner: PACIFIC CREST PARTNERS SCHOLLS L
7000 SW HAMPTON ST, STE 130
TIGARD, OR 97223
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 09/14/2015 $1,275.00
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .25
Total $1,275.00
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other a licable
law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issua e, or if
work is sus.• •-• . more the 180 days. ATTENTION: Oregon law requires you to follow the rules a...ted by the Or- on Utility tification
Center. ose rules ar- et fort in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a opy of the es or dir- questions
to OU by calling 503.232.1•: .r 1.:ra x.332.2344.
Is ued By: Permittee Signature: r / ( / i
Call 503.639.4175 by 7:00 a.m.for the next available inspection,/te.
This permit card shall be kept in a conspicuous place on the job site until coy.letion of the project.
Approved plans are required on the job site at the time of each inspection.
Accumulative Sewer Tally
III Tenant Name: Straight Up Chiropractic SWR# 2015-00110
Site Address: 12700 SW North Dakota#180 PLM# 2015-00299
1IC;nn:,
Parcel#: 1S133AD16200
Fixture Value: Previous Previous Credits Capped Fixture Fixture Nevc New
# calue count capped#s value count added# added value total#s total values
Baptisery/Font 4 0 0 0 0 0
Bath: -Tub/Shower 4 0 0 0 0 0
-Jacuzzi/Whirlpool 4 I) 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
-flinch 6 0 0 0 0 0
-Car Wash 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
Living Unit 16 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) I 0 0 0 0 0
-Stall 2 0 0 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 1 2 0 -1 -2
-Bradley 5 0 0 0 0 0
-Com/Serv/Util-Food Related 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer-Clothes 6 0 0 1 6 1 6
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 2 1 6 0 4
Current Fixture Value 4 divided by 16= 0.250 Current EDU 1 EDU = $5,100.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 4 divided by 16= 0.250 over (under) $ 1,275.00
Enter EDU Change Here 0.250 *
*Round EDUs to the nearest 1/100th: a count ending in.005 shall be rounded up to.01,and a count ending in.014 or less shall be rounded down to.01.
Notes:
Authorized Name/Signature: Debbie.•ldamski Date: 9/14/2015
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\Sewer TallySheet_5100_070115.xlsx