5, <br />i <br />Public Works <br />MaintenanceLocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address ___:_____ <br />Map and Tax Lot—~ <br />Building Type: <br />91S Argcm A\ye <br />KavJ Y\ O Xyl r .-----------------------------------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 _ <br />AVnrfwfow granted to attach prtoata <br />\-\o-£o nDate of Issue____________ <br />Pipe Material pjpe Diameter^. <br />□ System Development Charge <br />L-a-CLg. < sInspected By <br />it conhtmfKTKi to Ctty ttandardm and tpoctihotiona.ccnnacdoa to piMfc <br />Public Wastewater Information <br />Index Page No. -- L/a3oo?ected BySegment No.Contract No.Ups tr com Downstream <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344/b <br />N <br />L <br />sr <br />tt. <br />/? <br />0 <br />i <br />! <br />. f. -