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i#" <br />* -■ii <br />Public Works <br />MaintenanceCANN£d©Location of <br />Wastewater Connection <br />O <br />1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address ■_____ <br />Map and Tax Lot__I <br />Building Type: ^fSFD <br />M57 Park PL. _____ <br />Owner ^hri5 F;fa.L)k\ <br />□ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Informat on <br />Permit No. I ^ H ~O l <br />Contractor/Plumber E P(X0\A_CYC- <br />□ Right of Way Cut Permit Required <br />Installation Date __I "IM_____________ <br />Pwmhtkm graiM to attach prtoot* —w econ*cUo* to pobBc <br />5rh.^0 <br />Date of Issue <br />Pipe Material- <br />□ System Development Charge <br />. Inspected By __Lfl-Ca SSG <br />// <br />Pipe Diameter. <br />h confcmv»anc» to CXy itandardi and ycfflbaflbn* <br />Public Wastewater Information <br />Index Page No.-\mlnspeUpstreom DownitrfemSegment No.Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG. CALL U71UTY ONE-CALL SERVICE AT 1-800-332-2344 <br />Conne.c+ -\o <br />\y/$ <br />\/ <br />/5 <br />y <br />CowaecAs <br />p0blic Sv/ste^ <br />Debf'C^ <br />on <br />i <br />i