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% bb^S <br />Public Works <br />MaintenanceLocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address ____:____ <br />Map and Tax Lot — <br />Building Type: <br />Dr.oan t n f'a.ra.Owner <br />^SFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Information <br />Permit No. ( ^ ' 003 H Ll ~ O i________Date of Issue l ’ 39*1^ . /• <br />Controctor/Plumber _Ly^Va/iior. ^ pipe Material_^0 pjpe Diameter_l_ <br />□ Right of Way Cut Permit Required <br />Installation Date ____H ~ ~ ^ ' <br />fWmWcyi grant*/ to <rttoch prterit <br />□ System Development Charge <br />U<a.(La <br />h ccnfafTmyjncm to CXy •ianOarrh and tptcHhation* <br />Inspected By <br />connection to pubOc <br />Public Wastewater Information <br />Index Page No~7 ~] <br />Inspected By _ <br />DowrVaircornSegment No..Contract No.Upstreom <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERMCE AT 1-800-332-23+4T <br />N <br />3 <br />& <br />\ <br />31' <br />T > <br />i"I <br />l <br />o