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bMl I <br />Public Works <br />MaintenanceSCANNELocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address ____:____ <br />Map and Tax Lot — <br />Building Type: g| SFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />ftzT Av& <br />Owner <br />Permit Information <br />Permit No. <br />Pnntrnrtnr/Pli imhpr- l^aPipp. Mntfrtnl Pipe Diameter ^ <br />Date of Issue <br />□ Right of Way Cut Permit Required <br />Installation Date \ O / Z. j ------ <br />□ System Development Charge <br />ctmwctibn to pubOc *•*«- *t canfomnanc* to CKy rtandardm andPermJmlon granhd to aitoch prtnjtm <br />Public Wastewater Information <br />Index Page No. <br />-----J ' , _ Inspected By _ <br />LLk^ Segment No.l^^------------Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG, CAU. UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />\ <br />4 U-tMt <br />I38 <br />Tt&S'-^6 ^ <br />IT Mol/21 2o? <br />O O