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Public Works <br />MaintenanceSGANN <br />1 <br />Location of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Eugend, Oregon <br />(541) 682-4800 <br />•< <br />97402 <br />Property Information <br />Address ____:_____ <br />Map and Tax Lot__~ <br />Building Type: ^TSFD <br />iSHO A\J£, <br />Bruce._______________:__-— Owner <br />□ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Information <br />Permit Nr> 1 ^ ^ 03 1 ~ Ol_______Date of Issue // <br />r.r.n^m^^r/PlnmbRr Pipe Mntfirinl SC,V\.ulO pipe Diameterfi— <br />□ Right of Way Cut Permit Required <br />Installation Date <br />PomMon grant*! to attach prtmfa <br />□ System Development Charge <br />1-CL.C.a <br />to CXy ttandard* and tptdlfcaihnt. <br />*7-3 q-R Inspected By <br />connoctha to puMc h <br />Public Wastewater Information <br />Index Page No <br />Inspected By <br />Segment No. J&ljl--------Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />Q ^3n 1 X)eicbu\eS Ave./T' <br />i <br />6' d^epi 7 <br />V? <br />I50 <br />% <& <br />yrt So <br />vi^