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5r <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 />Oarme] A\ie.. <br />KrtvLi il nrvA: ____________:_____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 ------------S"" <br />ao-oolZC-ot Date of Issue 3 ~G~ d-Q n <br />Pipe Mntfirinl -SC ^ & Pipe Diameter^i__ <br />□ System Development Charge <br />C./iInspected By <br />h cantormnanc* to CXy ttondardi and ycflfartfen*ccnryctioa to puttiePwml—kti gmnt»d to attach prtvatt <br />Public Wastewater Information nspected By _ <br />Index Page No. ~1 7— Segment No.Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG. CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />■I <br />/K <br />i <br />/ <br />i <br />i