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h&'AV <br />^.Public Works <br />Pa Maintenance <br />l*^1820 Ro.Oseveit Blvd. <br />Jr Eugeni,- Oregon 97402 <br />(541) 682-4800 <br />Location of <br />Wastewater Connection <br />Property Information <br />Address ____1:—:——Lm <br />Map and Tax Lot — <br />Building Type: □ Duplex' "□'Multi-Family □ Commercial .□ Industrial <br />AVe\)CK <br />Bruce '> A/i^chcY fOwner <br />Permit Information <br />Permit No. <br />Contractor/Plumber Pipe Materializ-C-h-HO Pip <br />□ Right of Way Cut Permit'Requiredc, ^o-iq <br />Date of Issue •i <br />He Diameter. <br />□ System Development Charge <br />__ inspected By U-Q-CaInstallation Date <br />, frrmhtfcn eronM to Modi prfmi* t cemciScn fa pubOa —wr h ccnfomncnc* to Ctty thndarxfa end tpicHkaVa*.i <br />Public Wastewater .Information. <br />Index Page No. <br />spected By _ <br />UowMtrtomHISegment No,Contract No. <br />T <br />N <- 101 <br />av <br />14’ <br />#7 <br />3' <br />^37 <br />r