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r. <br />•f <br />■ <br />> i <br />i <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 />A\ie.. <br />-rtc LLC.Owner <br />SFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Information ^ <br />Permit No. / 9 __ <br />Contractor/Plumber J — <br />□ Right of Way Cut Permit Required <br />Installation Date <br />PwrmMcn arant*d to attach pttmta <br />n-ao-iqDate of Issue <br />Pipe Material- <br />t / <br />H-SC \r HO Pipe Diameter. <br />□ System Development Charge <br />La CazSfi9-IO-QO Inspected By <br />to conformnanco to Ctty •iandardt and ipodtfcatlana.cowcdoCT to ptMfc <br />Public Wastewater Information <br />Index Page No. <br />_ Inspected By <br />Segment No. -----J ll -51 Contract No.Downstream <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />/l/CSh)CCo-/ <br />-y4 <br />\ <br />t <br />23 <br />!i <br />]k H i <br />n <br />, *