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i <br />Public Works <br />MaintenanceLocation 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: <br />Msqo / £ -h <br />Owner \fJie.c her~t~ <br />FD □ Duplex □ Multi-Family □Commercial □ Industrial <br />Permit Information <br />Permit No. _19-0^0^4-0/Date of Issue ' 1 Q~ i 4 <br />Cnntrnrtnr/Pliimhfir-3fL./L.. Pipe MnterinlScL.4Q h!Pipe Diameter. <br />□ Right of Way Cut Permit Required <br />Installation Date 'oM ~ 19 :______ <br />Ptrmhtien mmjtd to attach prt/atm <br />□ System Development Charge <br />. Inspected By <br />canAymrtanc* to Qty ond wp^cMfcoHoos.con/yctfon to pubtfc <br />Public Wastewater Information <br />Index Page No., <br />Inspected By — <br />3 ZZllXQZSegment No.Contract No.Downstream <br />TWO WORKING DAYS BEFORE YOU DIG. CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />-A3P' f 18'> <br />/ <br />I'T <br />35 <br />Vg v^. <br />v?