Public Works <br />^^Maintenance <br />“■y 1820 Roosevelt Blvd. <br />y Eugend,- Oregon 97402 <br />(541) 682-4800 ' <br />Location of <br />Wastewater Connection <br />Property Information <br />Address ------1 <br />Map and Tax Lot — <br />Building Type: gfsFD □ Duplex MultM-Family □ Commercial □ Industrial <br />■ '7<£-5~ Ty.<.<3n Lf). ■ <br />Owner nay Jen Homes Jp/ic. <br />Permit Information <br />Permit No. ^ <br />Contractr'r/Pi"mLer O H. Lg<lh-i..p|pe Material bsC h- HO pipe Diameter. <br />□ Right of Way Cut Permit’Required □ System Development Charge <br />/ (9 ~/ 9_________ Inspected By L.ctLLn S S<2- <br />\c\-nl‘HHl -Ql Date of Issue /Q.~ 3/ '.19 // <br />3 <br />Installation Date <br />, Prrmhslcn eraiM to Moch prfwrf* »*wtr cerweffon fa pobfia rrrtr h conkmncnc* to Oiy atondarch and $r»cMcaVont. <br />Public Wastewater Information, <br />Index Page .No. <br />^ Inspected By . <br />Upstreom Down«reani~Segment No.Contract No. <br />l_ <br />f )0'^ <br />7 <br />H'[/g <br />5:iof <br />i.5 <br />& <br />nr <br />#33013 La.