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tpbS'Q^] <br />Public Works <br />Maintenance <br />1820 RoOsevelt Blvd. <br />y Eugeni,' Oregon 97402 <br />(541) 682-4800 <br />Location of <br />Wastewater Connection •< <br />Property information <br />Address ------—:— <br />Map and Tax Lot — <br />Building Type: ^TSFD □ Duplex ' □ Muiti-^Family □ Commercial □ Industrial <br />1197 "Aff\lr\n Park PL-8 Thomas U/i/f'rrOwner <br />Permit Information . <br />Permit No. 30' 011 I ....— <br />"fplftn \aJ* l fg tT Pipe Material _6C h ■ ^C Pipe Diameter. <br />□ System Development Charge <br />Rrrmtezbsn pcnM to Modi prfvato —wr eemctko to pobOo *wr h ccckfmncrK* to Ctty tterxfarda and tptcfffcaiknt. <br />Date of Issue 4" <br />Contractor/Plumberl <br />□ Right of Way Cut Permit Required <br />Installation Date -----~ ^ ^ ~ —Inspected By <br />Public Wastewater .Information.. <br />Index Page ..No.,—-J—----- Segment No.. <br />jnspec <br />uownstrftqm Contract No. <br />hi <br />/l\ <br />60^