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f!■i <br />Public Works <br />MaintenanceLocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Eugeng, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address ____:_____ <br />Map and Tax Lot ' <br />Building Type: <br />U57^, r-L <br />-----:--------Owner <br />□ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Informa ion <br />Permit No. <br />Controctor/Plumher E-'iOC.- <br />□ Right of Way Cut Permit Required <br />ccmcVoa to putOc <br />H-030^3-0!Date of Issue fj' IQ f 9 <br />Pipe Mntftrinl .9ch. Pipe Diameter_li <br />□ System Development Charge <br />. Inspected By _________ <br />h con/ormnanco to Oty riandanit and ipoctllartfon*. <br />'/ <br />Installation Date <br />Pwrolmlon granM to attach /vftofa <br />Public Wastewater Information <br />Index Page No.,— 0 <br />Inspected By ----- <br />Downstream^ Contract No.Segment No.Upstream <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />5"(o'' ^ <br />35^ <br />3^ <br />/ <br />/ <br />f