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665 «I <br />I <br />r Public Works <br />.Maintenance______ <br />11820 Roosevelt Blvd. <br />Eugend,- Oregon 97402 <br />(541) 682-feOQ <br />Location of <br />Wastewater Connection <br />S 'n,ormatton 3.37V <br />Map and Tcix Lot <br />Building Type: ^SFD □ Duplex □ Multi-Family □Commercial □ Industrial <br />Owner /irur/ Ttolck/ i-C UJ Koujici <br />/ <br />Permit Information <br />Permit No. ^— <br />Contrar'tr'r/Pl"mLpr Kf°.Wfy\ PiC-kvie/i ..Pipe Material Cch-L/C> Pipe Diameter_3 <br />□ System Development Charge <br />Inspected By _________________________ <br />h ccntorrriitaic* to Oty •tarxknh aid mocttfcot/cn^ <br />3-n-nDate of Issue // <br />□ Right of Way Cut Permit Required <br />Installation Date /I (3------------- <br />PrimMon to atioc/i prfwrf* wr cawTOdton to potto <br />Public Wastewater Information. <br />Index Page No. <br />Inspected By <br />UbmtxrtramIIHSegment No..Contract No. <br />t <br />N <br />VL) <br />"D