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•j <br />Public Works <br />Maintenance <br />1820 Ro.Osevelt Blvd. <br />Eugeni,-' Oregon 97402 <br />(541) 682-4800 <br />Location of ; • <br />Wastewater Connection <br />Property Information <br />Address -------1:— ------ <br />Map and Tax Lot—HI <br />Building Type: ^TSFD <br />~7£l Al AMron <br />VWy<4erv UornfiT, Xnc.Owner <br />□ Duplex "□ Multi-Family □ Commercial . □ Industrial <br />Permit Information <br />Permit No. t0! ~ O.^Ipo.1^ _____ Date of Issue '-'J ' II n <br />A tA L-exxyv\__^Plpe Material ^Cc\n<MO Pipe DiameterC^Contractor/Plumber'£Xn <br />□ Right of Way Cut Permit Required <br />Installation Date -----^ ' <br />Prarhsicn yrynM to attach prtoaH <br />□ System Development Charge <br />Inspected By _____C-a. <br />h ccnformnak* to Ctty atcrKfanfa and tp^cftkxrtkxy*.fa pobOa <br />Public Wastewater .Information.. • <br />Index Page ..No. <br />Inspected By <br />•3M Segment No..Contract No. <br />34' <br />-HD3iw <br />=#(93001A Aye,.