Report t? 4 Svc `.2. ` ~ . .M.
STATE OF OREGON, Jt?/ . 20/ ,V/777 0-t WELL ID#L No e_ ____._._..
WATER SUPPLY WELL REPORT ,
(as required by ORS 537.765) KYL. DRIL Gs.INC START`CARD# W103485Q_�.•�_.
Instructions for completing this report are on the last page of This form ,isosigte,7°'
(1)OWNER: Wet Wumberi 01 _m (9)LOCATION OF WELL by legal description:
County 1iUashln$tori
Name ._Uxa.itecl Excavators.Inc Latitude _..,__ Longitude
- Township, SQ j N er S. Range _...Am/Es ' E or W.of-WM.
Address 41( 1 S.i atiaalrly Etty ,.S#ta 12_emlit 361 _ Section. 0£r
KW. eta SE tib
Oil_-,;µ..Portland . .........___.M.State.�Zip.912 .._.... ._ Tax lot 25106RA it6 0 Stoc __.__._: Subdi sislon
(2)TYPE OF WORK: Street Address of Well(or nearestaddresss)J.3240.sytRay Rogem_____T
Ild<<NeWWell LDeepening ...wAlteration(repairlreconditionj Abandonment " DK. --4- ___........_.................__
(3)DRILL METHOD:
STATIC WATER LEVEL:
147 _fL below land surface. Date.611212017. ,
Ici Rotary.Air Rotary Mud Catale Auger Artesian pressure lb.per fit043.-
-
r Other_ (11)WATER BEARING ZONES::
(4)PROPOSED USE: Depth atwhichwaterwas firs€.iound
X Domestic i_l:Community C Industrial Obligation' itY L u
.Thermal 0 injection _Livestock 1'Other _ _ From ? To _____ /^►Esbma _E g ;.AWL
(5)BORE HOLE CONSTRUCTION: — _._.. _. __._..___.. �� t�.h.VLiAtilLJ
Special Coristruction approval Lyes i No Depth of Completed Well:Q _:___ft _ _...._.. .__
Explosives used Oyes licjblo Type Amount _..-...
HOLE SEAL . Amount (12)... LL LOG:
. __..._.. .... .
Diameter,Frain To l Material ,From To sacks or pounds
•
Grown d elevation
_...,,.,1_,,L.____
Cetn °Ir,
etit w1 , _.;..._22{3 . —
_ bentonite i 5 i.40 Sacks.___—_ ....-Material._ ........ ,.... ....... ; From __ To SWL
Bentonite 51 3 2_Sacks---_ tAtandonment.Only jf.l!A51 $4__
Calculated ._.__..__._ ' __.._135 Sacks ._
Howwasseaipiaced: Method LA _ �_
(Other PtICCiI .1 t33:f2hS?itt±,. of Cl I}ert$Qllite_ - _? _, ILUEIG .IN .
Backfill placed from it to ft. Material — — _
_ ..------------50$4564683—__--. 50$4564683 -�_ : ___,— __—___:
Gravel placed from. ft.to ft. Size of gravel
(6)CASIN GILINER: ____... .___ . ...._....__..
Diameter From To Gauge I Steel. Fleas Welded Threaded j' I
Casrn 2.11. ....„25.01 1(1 0 ;XI
Exlstng _ _1. L . , L
........_—__L__....4.................4...___......4. 0 Li .....,
L
Liner: lone _ l m 1 l ___. _ — ._.__..._.._ __
—_ _ L 0 . L —
Drive Shoe used (._Inside _ Outside _.... ..
None
Final location of shoes} MA
(7)PERFORATIONS/SCREENS: _..._.___� ..___. ..............._.._.._........_..... • •;..._...... _.:__ ..._.__
4.
X Perforations Method Atupetfoi'atot"
Screens Type .___-_.._.__ __._.. Material _,_.....__..._ :_.._... ...,..
•
Slot Tele/pipe —
From To size. Number Diameter size Casing Liner
_ ...._..:...__�_._..._ _.__M__ .�
0 21_.,�II$x1. —300 ' 0 _.._. .
t n.. Date started Com leted
µ,ms. __._.__,_.____m_. __.__ L.;. '� �t1.1212017 Completed SC1.;3�017
C (unbonded)Water Well Constructor Certification:
ri L I certify that the work I performed on the construction,alteration,or abandon-
ment of this well is in compliance with Oregon water supply well construction
(8)WELL TESTS:Minimum testing time:Is 1 hour standards,Materials used and information reported above are_true to the best of my
.m
Pump. _'Bailer ir Alt 0 Flawing Artesian knowledge and belief.
WWWC Number 1884
Yield gal/min Drawdown Drill stem at: _ • lime Signed Date 61i.8/2.=.17
N/A 1 1 1 SkYles Drilling,Inc. ,
Imo._.�_.-----._._`
:•
_ (bonded)Water Weil Constructor Certification: ,
•
Iacceptresponsibility for the cocatrirptlon, alteration;orabaridon ntwork
performed on this well during the construction.dates reported above: All work
Temperature of Water Depth Artesian Flow found performed during this time is in compliance with Oregon water supply well
Was a water analysis done? Li Yes By whom construction standards;This report is true to the best of My knowledge and belief:
Did arty strata contain watereot suitable for intended use? DToo little WWC:Number ins. ..
ty r-Muddy ;Odor Celoreci
.._`Sar ';Other • Signed ► to
Depth of strata: . - _ . Skyles Drilling,Inc.
ORIGINAL-WATER RESOURCES.DEPARTMENT FIRST COPY-'CONSTRUCTOR SECOND COPY-.CUSTOMER
RECEIVED
Qff-P�J 7-- eo e 9/ DEC 18 2018
CITY OF TIGARD
BUILDING DIVISION
"' - ,,,,,,,-
q, - 'r,
STON,0R05I1 INVOICE#
:� GASi ON,tlR 97119
0830 !
=- 503-522-2727
DATE
L503-687-2381 FAX JOB# Xj TECHNICIAN ,: #a1`
CUSTOMER.�tifI ) _AG ✓pe .r
(503) ROY PODcr s
CITY ajeY+ 00f7 7 STATE (i ZIP ` l' l0
I HOME PHONE# ( . )
522-2727 .
.,-.,. 717 7: CONTACT# ( )
CCB#202772 ' Q
DLI#WESTSSD874BC • FAX# ( ) TME IN •0 ,'PM
El.YES DAYS , . GUARANTEE NO TIME OUT 9I'' s/PM
DRAIN NEED FLAT
S RUTH. WORK PERFORMED
DRAIN CLEANING
SURV. HOURLY / ADD.DRAINS
MAINLINE HOURLY � - .),avO Cj'Qt 1&Ulkt SEF' I'CPUMP/,O1Z) 6,'a(,—
KITCHEN SINK. FLAT C 7 K. , i carol tst i i(1 ,` GREASE PUMP
LAUNDRY LINE FLAT ; // VIDEO INSPECTION • ,
BATH SINK FLAT WATER JETTING'
BATH TUB FLAT PLUMBING
SHOWER FLAT • EXCAVATION
URINAL FLAT PRODUCTS
TOILET FLAT • PARTS
FLOOR DRAIN FLAT LABOR •
AREA DRAIN HOURLY . DIAGNOSIS FEE . •
RAIN DRAIN ,HOURLY LINE LOCATE
SEPTIC GAL. ,Si r • ROOF/2ND FLOOR
SECOND MAN
. APPROVAL CODE# CHECK
PARTSRECOMMENDATIONS
�
QTY, PART# DESCRIPTION PRICE' I ErNZYME TREATMENT DEO INSPECTION . .
0 ROOT KILLER 0 PIPE REPAIR/REPLACEMENT TAX
YYANLJA
NL MAINTENANCE 0 CLEANOUT/INSTALLATION
NATER SETTING PAYMENT R€CEIVfD '
• BALANCE DUE -.:--5-0
ADDITIONAL TERMS AND CONDITIONS CONTAINED ON -
THE REVERSE SIDE OF THIS SHEET
V'WW.WESTSIDEDRAINANDPLUMBING.COM • ACCEPTANCE OF ESTI TE A.ND TERMS AND CONDITIONS ACKNOWLEDGEM IT OF CO'PLETION
•
CITY OF TIGARD SITE COPY BUILDING PERMIT
:I I COMMUNITY DEVELOPMENT Permit#: BUP2017-00041
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 02/28/2017
T f t_;A I F) g Parcel: 2S1060001401
Jurisdiction: Tigard
Site address: 13240 SW ROY ROGERS RD
Project: River Terrace East Apartments Subdivision: None Lot: None
Project Description: Demo 2,300 sq ft house and 864 sq ft barn,on septic. Septic tank must be pumped and filled or removed. Upon
approved final inspection demo credits may apply to future construction.
Contractor: NORTHWEST EARTHMOVERS INC Owner: POLYGON WLH LLC
PO BOX 1609 109 EAST 13TH STREET
SHERWOOD, OR 97140 VANCOUVER,WA 98660
PHONE: 503-625-3100 PHONE: 360-695-7700
FAX: 503-625-3108
Specifics: FEES
Description Date Amount
Type of Use: SF
Class of Work: DEM Type of Const: Permit Fee-Additions,Alterations, 02/28/2017 $509.05
Demolition
Occupancy Grp: Occupancy Load: Erosion Control w/Development 02/28/2017 $107.60
Dwelling Units: Info Process/Archiving-Sm$0.50(up to 02/28/2017 $2.00
Stories: Height: ft 11x17)
Bedrooms: Bathrooms:
Value: $30,000
Floor Areas:
Total Area:
Accessory Struct:
Basement:
Carport:
Covered Porch:
Deck:
Garage:
Mezzanine:
Total $618.65
Required: Required Items and Reports(Conditions)
Fire Sprinkler: Parapet:
Fire Alarm: Protected Corridors:
Smoke Detectors: Manual Pull Stations:
Accessible Parking:
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 by the Oregon Utility Notification Center. Those rules are set forth in OAR
952-001-00 nrough• <952-001-0090. You may obtain a copy of the rules or direct questions to OUNC by call.• _13.232.1987 or 1.800.332.2344.
n �
Issued By: % I /• , !� 1 Permittee Sign lure: ? F/ //�
Call 503.639.4175 by 7:00 a.m.for the next available inspe on date.
This permit card shall be kept in a conspicuous place on the job site • it completion of the project.
Approved plans are required on the job site at the time of each inspection.
•
Inspections Required for P nit No.: / irn — :
IVR Code Type Permit Description IVR Code Type Permit Description
01 BUP Building—structural 07 SIT Site Work
02 ELC Electrical 08 SWR Sewer Connection
03 ELR Restricted Energy 09 FPS Fire Protection
04 MEC Mechanical 10 RER Re-Roof
05 MST Master—residential combination 11 CMS Commercial Manufact.Structure
06 PLM Plumbing 12 SFM Single-Family Manufact.Structure
J Req'd Code Inspection Description I Req'd Code Inspection Description
Building(structural)Inspections Electrical Inspections
205 Footing 105 Underground/slab cover
210 Foundation walls 110 Temporary electrical service
215 Footing drain 115 Electrical service
220 Slab 120 Electrical rough-in
225 Post/beam structural 125 Wall cover
230 Underfloor insulation 130 Ceiling cover
240 Exterior shearwall 135 Low voltage rough-in
242 Interior shearwall 140 Sign installation
245 Firewall 145 A/C or heating unit circuit
250 Roof nailing 150 Hot tub/spa/pool
255 Wtr proofmg basement walls 195 Misc.inspection
260 Tilt-up panel 198 Low voltage fmal
265 Masonry 199 Electrical fmal
270 Reinforcing steel(rebar)
275 Framing Mechanical Inspections
280 Insulation 605 Post/beam mechanical
285 Drywall nailing 610 Gas line
287 Suspended ceiling 615 Mechanical rough-in
289 Approach/sidewalk 620 Hydronic piping
X95 Misc.inspection 625 Duct work
"- 299 Final inspection 630 Fire damper
635 Smoke detector shutdown
Fire Protection System Inspections 640 Exhaust hood
901 Sprinlder supply lines 645 Grease duct test
905 Sprinlder underfloor/slab 695 Misc.inspection
906 Flush test 699 Mechanical final
907 Sprinlder hydro test
910 Sprinkler rough-in/test Plumbing Inspections
915 Fire alarm rough-in 305 Plumbing underslab
920 Suppression trip test 310 Crawl drain
995 Misc.inspection 312 Backwater valve
998 Alarm fmal 315 Post/beam plumbing
999 Sprinkler fmal 320 Plumbing rough-in
322 Shower pan
Site Work Inspections 330 Water service
405 Excavation 335 Rain drain
410 Fill 340 Storm sewer
415 Grading 345 Culvert/catch basin
495 Misc Inspection 350 Septic tank
499 Final Inspection 395 Misc. inspection
399 Plumbing final
Sanitary Sewer Inspections
505 Sanitary sewer
Erosion Control Inspections 585 Misc. inspection
750 Initial erosion control 599 Final inspection
752 LIDA on-site facility inspection
755 Regular erosion control Manufactured Structure Inspections
797 Final LIDA inspection 810 MFG-Structure set-up
798 Final erosion control 899 MFG-Structure fmal
I:\Building\Forms\Inspection Cards\AOP Insp Card By Case\InspCard_All_031816.docx