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Public Works <br />MaintenanceLocation of <br />Wastewater Connecti 1820 Roosevelt Blvd. <br />EugenO, Oregon 97402 <br />(541) 682-4800_________________ <br />Property Information <br />Address __:__:____ <br />Map and Tax Lot — <br />Building Type: <pp> SFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />^?<r 3I&T7+- A <br />Owner <br />Permit Information <br />Permit No.________ <br />Contractor/Plumber. <br />□ Right of Way Cut Permit Required <br />Installation Date <br />PwmMon aranM to attach prhata amnr ccnmMoa to pobOc T it ccnformnonca to Oty tiandarda and tpacMart/an. <br />Date of Issue <br />Pipe Material. <br />/" <br />Co -in?.Pipe Diameter. <br />□ System DevelopmentQ^arge <br />Inspected By ____ <br />- <br />Public Wastewater Information <br />Index Page No. <br />Inspected By <br />Segment No.Contract No.Upstreom Downsireom <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERMCE AT 1-800-332-2344 <br />ty9)P&tUATf Ot/CJ/7/do'U OrlooCo♦ <br />\OV loo’10 >I <br />Co Co <br />(r 0 /-r <br />i <br />j\) 2>k>r/f .