Permit (119) CITY OF TIGARD SEWER CONNECTION PERMIT
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COMMUNITY DEVELOPMENT Permit#: SWR2018-00236
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/17/2018
T f'GtFt.1 Parcel: 2S103DD01100
Jurisdiction: Tigard
Site address: 13939 SW PACIFIC HWY
Project: Providence Retail Clinic Subdivision: None Lot: None
Project Description: .25 EDU Increase
Contractor: Owner: WALGREEN CO#5780
PO BOX 901
DEERFIELD, IL 60015
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 10/17/2018 $1,412.50
Type of Use: COM
Class of Work: ALT
Install Type: Line Tap
Fixture Units:
Number of Dwelling Units: .25
Total $1,412.50
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable
law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if
work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted ., the Oregon Utility Notification
Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a cop t$f the r les or direct questions
to OUNC by calling 503.232.1987 or 1.800_33223_44. f
Issued By: Permittee Signature: /`
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C . 39.4175 by 7:00 a.m.for the next available inspectioy.ate.
This permit card shall be kept in a conspicuous place on the job site until c. pletion of the project.
Approved plans are required on the job site at the time of each nspection.
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IIIC Tenant Name: Providence ExAprecssuSewTally SWR# 2018-00236
TI G n R D Site Address: 13939 SW Pacific Hwy PLM# 2018-00487
Parcel#: 2S 103DD01100
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value 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 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 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
-4inch 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) 1 0 0 0 0 0
-Stall 2 0 0 0 0 0
Sink:
-Lav/Bar-Non-Food Related 2 0 0 2 4 2 4
-Bradley 5 0 0 0 0 0
-Com/Sery/Util-Food Related 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
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 0 0 2 4 2 4
Current Fixture Value 4 divided by 16= 0.250 Current EDU 1 EDU= $5,650.00
Previous Fixture Value 0 divided by 16= 0.000 Previous EDU
Change 4 divided by 16= 0.250 over (under) $ 1,412.50
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: Dianna Howse Date: 10/16/2018
Building Division
INote: 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_5500_070117.xlsx