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!t: bbwb <br />4i <br />Public Works <br />MaintenanceLocation of <br />Wastewater Connect 1820 Roosevelt Blvd. <br />Eugeng, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address ____:___ <br />Map and Tax Lot_ <br />Building Type: <br />£IKh/ir^ Dr. <br />-TbrdavA X verson <br />FD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />Owner <br />Permit Information <br />Permit No. j ~^ ^ '________Date of Issue i P ^ <br />Contractor/Plumberj33_^i_'^r^ipe Material____________SC-K- ^0 Pipe Diameter__l. <br />if <br />□ Right of Way Cut Permit Required <br />Installation Date <br />/Wmfufcw aranM to attach prtvata <br />□ System Development Charge <br />4 se.Inspected By <br />corracflbn fc> piMfc mawar h canformnanca to CXy ttandardm and *p*cft!caifon*. <br />Public Wastewater Information <br />5H <br />Upstream DownstreomSegment No.Index Page No.-Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />#3^3 <br />3 y%Q l <br /><3 <br />*-0 <br />! <br />I <br />I3H <br />1