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■ : <br />S-, <br />4 Public Works <br />Maintenance <br />1820 Roosevelt Blvd. <br />Eugen6, 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: □ Duplex □ Multi-Family □ Commercial □ Industrial <br />hlzrAot-Ca A\je. <br />^nc.laL\/e LL(LOwner <br />Permit Information <br />Permit No. <br />Contractor/Plumber <br />Date of Issue <br />Pipe Mntfirinl pipe Diameter.V" <br />□ Right of Way Cut Permit Required <br />Installation Date <br />PwmMon granttd la attach prtvata <br />□ System Development Charge <br />L-(xC^a.sSe--AO Inspected By <br />*» canformnanca to Oty atandarcta and wpacMcatfcn*.connoctfo* to pubth <br />Public Wastewater Information <br />Index Page No.Upstr^m ~ Pownstreom <br />i77 Segment No.Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG. CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />/ <br />51< <br />Off is <br />7g <br />a<?'