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PERMIT NO.
ADDRESS - - - —
PERMIT CHARGE
! CONNECTION FFE
OWNER
.Z
PAID BY _
TYPE OF BUILDING .ae.�-*� 44-- DATE CONNECTED
SERVICE RATE - INSPECTION FEE c�s
. CONTRACTOR PAID BY r z. , DATE
ASSESSMENT PAID
SItE OF CONNECTION y� _ __-__� ___
City of Tigard
INSPECTION REQUEST
for
IINSPECTION TIME :.A---"'— PERMIT NO.: _--
DATE: j2 DATE ISSUED: 1
I OWNERS NAME : �
ADDRESS :
CONTRACTOR :__ -- LL
Laboratory []
TE�'T; Air Cl, Nater CJ ► Visual ,
I
op
RESULT'. L7 , pending [I: Approved ,
SKETCH:
i
I
I
I
I
I INSPECTOR
DATE
(NOTE: Attach supplemental test dato heret:01
GE AGENC'� No. 471
UNIFIED SEWERAGE �
_.
WASHINGTON COUNTY DATE
CITY OF-----
AC
F_-A( LICATION FOR SEWER CONNECTION PERMIT
OWNER: ...
OWNER'S ADDRESS: /��/U '— QC' PELT
-11 ZIP
STATE.
CIV y ADDITION
BUILDING SITE: LOT- - -
BLOCK ------- - - -
/5/ 360
TYPE OF OCCUPANCY
TAX LOT N0.
ADDRESS
DWELLING UNITS--- --
_f_.__------------- FIXTURE UNITS
SURCHARGE IF APPI-ICABLE ------- --- � '�--
-
INSPECTION FEE Si TOTAL DEPOSITED
PERMIT FEE - - -
(NEW) (EXISTING) BUILDING SEWER SYSTEM _--- -- - -
fthe ii�fSewerage Agencv.
The Applicant agrees to comply with all rules a d requl do i
PPLICAN7
SEWER PERMIT
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER` SYSTEM. -- --
LINE SIZE ----- T/I INSTALLER _ ---
RECEIVED BY_- - in ,i- ,r oITS eNf
COMMENTS
lQCtiGKtJ
_ I
This Application and uermit expires in ninety (90) days. The amount paid will be forfeited
should expiration occur.