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bbb'bOi-f <br />Public Works <br />MaintenanceLocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Euqend, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address ____:____ <br />Map and Tax Lot — <br />Building Type: 0 SFD <br />Pierce ST <br />Pfyuv ScAlLVOKl,_______________:_____Owner <br />□ Duplex □ Multi-Family □Commercial □ Industrial <br />Permit Information <br />Permit No.Date of Issue 0\f c^j2O <br />Cr.n^rn^r.r/PliimhF!r <U\\P>b&. (Lccu-t-ipipe Material UQ----Pipe DiameterLi_ <br />□ System Development Charge <br />Inspected By Ll^^ <br />confominanc* to CXy standard* and spocHfcatfont. <br />p\ <br />□ Right of Way Cut Permit Required <br />Installation Date —^ ---------- <br />Pcrmhoton granM to attach prtmt*candoctioa to public mnr h <br />Public Wastewater Information <br />Index Page No.r <br />Inspected By <br />DownstreamUSSegment No.Contract No.Upstreom <br />TWO WORKING DAYS BEFORE YOU DIG. CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />f1'r-r <br />_ RepU<^. S€u3€/ui <br />r' <br />i i <br />SiptWAlX <br />113T <br />o^...... <br />1