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4 bb Public Works <br />MaintenanceLocation of <br />Wastewater Connection SCANN 1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />•f <br />Property Information <br />Address ____:____ <br />Map and Tax Lot — <br />Building <br />?£> IQ Po-tieir r, L <br />Rr/'aiA Hoi/rw--------------------------—-— Owner <br />□ Duplex □ Multi-Family □ Commercial □ IndustrialType: ^p-SFD <br />Permit Information <br />Permit No. 1 <br />Contractor/Plumber_Kip L-C>______ <br />□ Right of Way Cut Permit Required <br />Installation Date <br />/VmfcWcw grant*! to attach prtvaia <br />Date of Issue 'T ~ 1 ^ <br />Pipe Mnterinl ScK. HO <br />— // /I <br />Pipe Diameter^ <br />□ System Development Charge <br />LctGi^.Ce.^ -zo-1 ?Inspected By _ <br />*» confamnaoco to Oty standard* and tpacHkationa.connection to pubtk <br />Public Wastewater Information <br />Index Page No. <br />Inspected By <br />Downstream <br />1376 Segment No.Si Contract No.Upstreom <br />TWO WORKING DAYS BEFORE YOU DIG. CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />36*-1 Ait6 Tlpai?-o'T /17 v>V <br />js' <br />\J^ <br />i/ <br />^ pressu»-e QJ <br />pofcr L o;«o_3 <br />/