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j-:' <br />Public Works <br />MaintenanceLocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800IV <br />Property Information <br />Address ___—:— <br />Map and Tax Lot — <br />Building Type: 0 SFD □ Duplex □ MultH-Family □ Commercial □ Industrial <br />Tlob ClLGiTZ CT <br />M\vo \Nv/esrrMPMTi_LccOwner <br />Permit Information <br />Permit No. C\ <br />Pipe Mntftrinl UO pipe Diameter M <br />□ System Development Charge „ . <br />. Inspected By L\ --------- <br />h ccnfotmnanc* to CHy standards and tptcHkaihns. <br />Date of Issue <br />Contractor/Plumber <br />□ Right of Way Cut Permit Required <br />Installation Date .I| / 1 % J \ c{--------- <br />Pormkohn aranM to aitoc/t prtvots connection to puMc <br />Public Wastewater nformation <br />Index Page No. <br />Inspected By <br />Upstrearn Downstream47Segment No.Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />O 7'llTl <br />VT <br />0 <br />4 <br />K <br />o <br />A <br />id' ^ ^ 1 <br />»*7' <br />i <br />V?/ <br />\_n) <br />No