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bbte<\ „* .* <br />i ^ Public Works <br />Maintenance <br />“71820 Roosevelt Blvd. <br />y Eugend, Oregon 97402 <br />(541) 682-4800 <br />Location of <br />Wastewater Connection •« <br />Property Information <br />Address . '_:—Lj—:— <br />Map and Tax Lot — <br />Building Type: EG SFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />-T^lTO v • <br />CftfeSCfcMrT. \*4C.Owner <br />Permit Information <br />Permit No. _ <br />Contractor/Plumber <br />□ Right of Way. Cut Permit Required <br />Installation Date <br />Permkdan aranM to attach prtoata <br />Date of Issue ^ ^ <br />Pipe Mntftrinl r- ^ Pipe Diameterf~i_- <br />□ System Development Charge <br />Inspected By <br />onfominanca to Ctty Btarxtordw and wpact/katfoni. <br />rvk\1/ol/Zo <br />conhactha to.pubtfc <br />Public Wastewater Information <br />Index Downstr com <br />Inspec <br />Page .,No.. ~ — Segment Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG, CALL U71U7Y ONE-CALL SERVICE AT 1-800-332-2344 <br />I <br />Z'-V . <br />v-y <br />2'-Z h <br />!)r. \iVo <br />N <br />/^20o>o <br />V~14m