12210 SW SUMMER CREST DRIVE-1 I
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12210 SW SUMMER CREST DRIVE
Receipt #0 5633
SEWER PERMIT N° 211-92
Uf
unified Sewe'age Agency
of Washington County CIT'' OF Tigard DATE 5 1 ED
OWNER : Henry Mer.zentine PHONE : 630--2375
OWNER 'S ADDRESS : 12210 SW Summercrest Drive
TYPF OF IN'TAI_LATION:
® BUILDING SEWER [l BUILDING SEWER AND SIDE SEWER
TYPE OF OC'C�-'PANClY:
❑ NEW Cl SINGLE FAMILY ❑ COMMERCIAL
❑ EXIST. (r'RIOR Til 7- 1-70 ) ❑ MUI_T. RES. ❑ INDUSTRIAL
FIXTURE UNITS DWELI_ Ir ,'NITS 1
ADDRESS OF ST.; UCTURE : `.12210 SW SL!mmercrest Orive
PERMIT CONDI-IIONS: THE APPLICANT AGREES TO COMPLY WITH ALL RULES AND
REGULATIONS OF THE UNIFIED SEWERAGE AGENCY . WHEN CALLING FOR INSPECTION ,
PLEASE REFER TO THE PERMIT NUMBER . THIS APPLICATION EXPIRES IN ONE-
HUNDRED AND TWENTY ( 120 ) DAYS. THE AMOUNT PAID WILL BE FORFEITED SHOULD
EXPIRATION OCCUR .
FEES :
PERMIT FEE $ 2.x. 00
CONNECTION CHARGE
SIDE SEWEt, INSTALLATION Penny Liehertz
ISSUED BY
OTHLR
TOTAL $ 325.00
ys 1. AffPLICANT DATE �^
G,�T�. -'lri� uCl� ltl
;��s :GE ti'iiLL Ew31A FOR T1i-3
ritvlIT. S�'"BIER PERMIT
F:
N° 2112
ADOPaSS OF STRUCTURE _ 12210 SW Summercrz:st Drive
IAx MAP 151-34CB -- TAX L�. T 2000 SYSTEM Fanno reek
LOT 26 BLOCK _ _ OF Summar Hills Park
Dili -1--/ --
- -- -- &.L_ _
APFROVED BY� _ DATA ISSUFD BY DATE
D . U . ' S 1 _i _ REMARKS Existinq saptic tank to be pumped an i1 ) ad ___
with sand per State Code.
ALSO R r
SEWER PEREAT
Unified SewerageAgency
DATE
of Washington County CITY OF � `
0 W N E R ; ��mVV---/-/—I C.. srs��,►.�7!t '� PHONE
ADDRESS : tZ r
TYPE OF INSTALLATION :
BUILDING SEWER U BUILDING SEWER AND SIDE SEWER
/TYPE OF OCCUPANCY :
[� NEW )64 SINGLE FAMILY '-I COMMERCIAL
EXIST. ( PRIOR TO 7- 1--70 , ❑ �',ULT. RES. ❑ 1110USTRIAL
FIXTURE UNITS_ _ DWELLING UNITS_._.___
ADDRESS OF STRUCTURE : 9a*na--
PERPIT CONDITIONS : THE APPLICANT AGREES TO COMPLY WITH ALL RULFS . AND
REGULATIONS OF THE UNIFIED SEWERAGE AGENCY . WHEN CAI-LING FOR INSPECTIG^d ,
PLEASE REFER TO THE PERMIT NUMBER . THIS APPLICATION EXPIRES IN ONE-
HUNDRED AND TWF'T'Y ( 120 ) DAYS. THE AMOUNT PAID WILL BE FORFEITED SHOULD
EXPIRATION .000R .
FEES .
PERMIT FEE $_
CONNECTION CHARGE
SIDE SEWER INSTALLATION
OTHER Le/'��jjcm A I ISSUED BY
______,�,
TOTAL
APPLICANT DATE:
71r;
ADDRESS OF STRUCTURE .- �►t Q
N�
TAX MAP $� - -' Lam_ TAX !_OT ^_ Z�rUU _ SYSTEM _ FuAMO
LOT _z _BLOCK OF __ ,tiwtll,Br A4115 Pte.
A r ROb'ED BY DATE ISSUE) BY DATE
D . U . ' S REMARKS
1
City of �* i gard
INSPECTION REQUEST
INSPECTION TIME : 3--w P'4__ PERMIT NC. :
. .
DATE: /A6L DATE ISSUED:__(__L--
OWNERS NAME :
I
TEST: Air ❑, Water [I , Visual [I , Laboratory p
RESULT: Approved ❑ , Disapprcved O Pending (._]
SKETCH:
I �
INSPECTOR DATE
1N01'E : Attach supplemental test data heretj
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