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IpbZSO <br />4 <br />Co„„.e,,onSCANNEC^Public Works <br />Maintenance <br />1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address ■____ <br />Map and Tax Lot__: <br />Building Type: ^TSFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />L-LCOwner <br />Permit Information ^Permit No. 01 5i\3 ' O \ <br />Contractor/Plumber^2HL^_• <br />□ Right of Way Cut Permit Reauired <br />Installation Date ____I ' ^ — <br />'fDate of Issue <br />Pipe Material. <br />□ System Development Charge <br />J fVv~\ <br />h cenformnone* to CHy ttandarda and tpacmarthna. <br />HPipe Diameter. <br />Ua CaSCC.Inspected By <br />Pwmbaion arantad la attach prhata ceanactioa to piMfc <br />Public Wastewater Information <br />Index Page No. <br />i5^nsp^;iy^5~Segment No..Contract No.DownstreamUpstream <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 T <br />N <br />O <br />-f* <br />V93 7 <br />i <br />\1%