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t. <br />Public Works <br />MaintenanceLocation of <br />Wastewater Connectio 1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />" <br />Property Information <br />Address ____:_____ <br />Map and Tax Lot___ <br />Building Type: @ SFD <br />l5Sb AUt <br />----------------------------------Owner <br />□ Duplex □Multi-Family □Commercial □Industrial <br />Permit Information <br />Permit No. <br />Contractor/Plumber <br />□ Right of Way Cut Permit Required <br />Installation Date \Q i /.)f3-------- <br />PrmMon granttd to ottocA prtvato <br />Q7/\i/'q^-OMSS^-CA <br />g<WUM <br />Date of Issue <br />Pipe MaterialPipe Diameter ^ <br />□ System Development Charge <br />LA o w cK Kkyt /1 k I. Inspected By <br />conformnanco to CHy ttandordo andconnection to public <br />Public Wastewater Information <br />Index Page No.r U~7 Segment No.Contract No.DownstreamUpstreom <br />TW WORKING DAYS BEFORE YOU DIG. CALL UTTUTY ONE-CALL SERVICE AT 1-800-332-2344 <br />23.1 <br />XOr oIV <br />t <br />So' <br />. CO <br />co 'S <br />\0'i /no T "r @ S *f <br />Z-7r Vft,\ <br />\'-8 i <br />U