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bbHl'b <br />Public Works <br />Engineering <br />99 West 10th Avenue <br />Eugene, Oregon 97401 <br />(541) 682-8400 <br />Location of <br />Wastewater Connection <br />Property Information <br />25% 5 jkottiUOTAddress <br />Map and Tax Lot <br />Building Type: <br />Owner <br />Sifcommercial□ SFD □ Duplex □ Multi-Family □ Industrial <br />Permit Information □ Right-of-Way Cut Permit Required <br />□ Systems Development Charge <br /> Pipe Diameter fc <br />Permit No.Date of Issue <br />CgHSTlucTPH <br />Inspected By <br />Permission granted to attach private sewer connection to public sewer in conformance to City standards and specifications. <br />Contractor/Plumber Pipe Material <br />Installation Date <br />-\ZZ53 <br />Public Wastewater Information <br />Index Page No. ______ <br />Inspected by <br />Contract No. 20 <3.0*7Segment No. <br />upstmum DOWNSTREAM <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344. <br />uH <br />■I- <br />x <br />$ <br />(V <br />Ili <br />Jo " ten C <br />o <br />Co* 23^65 <br />2-65*) <br />White - PWM Yellow - Applicant Pink - PWE/PIC Gold - PWE FilePWE 0992 Rev. 0902