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i <br />Location of <br />Wastewater Connection ; <br />Public Works <br />Maintenance______ <br />1820 Roosevelt Blvd. <br />Eugeni, Oregon 97402 <br />(541) 682-4800 <br />ICQ.^ O^horg Rril .Property Information <br />Address • <br />Map and Tax Lot__o yOwner <br />Building Type: □ SFD □ Duplex IMulti-Family □ Commercial □ Industrial <br />Permit Information <br />Permit No. <br />Contractor/Plumber KipCft-_______ <br />□ Right of Way Cut Permit Required <br />Installation Date ___^ <br />rwmfc»fein grant*! to attach prtvata <br />\<Z-o.‘rs^2'0\Date of Issue ~7/, •( <br />Pipe Material ' Pipe Diameter^ y / <br />□ System Development Charge <br />LouCq £.se.Inspected By <br />h contormnanca to CHy itandard* and tpachhai/ana.connection to puhOc <br />Public Wastewater information <br />Index Page No- O / <br />i ^Inspected By _g48q ..n7qo <br />Upstream DownstreamSegment No.Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2544 <br /><£>f0 1033 Coboty <br />I <br />io-o